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FOR OFFICE USE: 10 >' r APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit NoZY:__7,5�'S" --------- This Permit Expires 1 Year From Date Issued Date Issued..__-=/S_75- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No, 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..r� _ _ M -.:�:_-` CENSUS TRACT Owner's Name__ h �" --------- . � - .... --------------- --------- ------------------------- . - --- - :----- one- ----. - -- ------ =---- Address ---- -------- ip ----- - Contractor s Name �... ,�lli i /Q city - z -. ---- ---- - .License # � �7� �__�----Phone' ' f/- { Installation:will serve: Resid ce ❑i Apartment House.❑ Commercial ❑ Trailer Court ❑ 3 � Motel [❑ - 'Other-------- ---:-- Number ofliving units:----- _.�Nuniber of_5edrooms-3--__-Garbage Grinder. ----------Lot Size---__ ---------------- I ; - me---- ---.---------- = :.. ------- ------------------- -=- -------------- -- Private Water Supply: P,ublic_System and:na Character of soil to a depth of 3 feet. Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam' op; Hardpan ❑ Adobe❑ Fill Material-.__.-;-...._If yes, type.__ ____________-----__, g crfti (Plot plan, showing size of lot, location of system in relation to'wells, buildings,'etc. must be placed on reverse side.) �1 NEW INSTALLATION: '(No septic tank`or seepage pit permitted if ublic sewe is available within 200 feet,] �.� � �}• s _ r f � PACKAGE TREATMENT [ ] SEPTIC TANK ['] 'Size___ � Pd�X . --_Li p �� r l - / C � y`T'r � � quid Depth ._ -f-------------�, Capacity< .-- -=Type�� -------`------Material---------=-----------=----No\Compartments_._4 ----f--- ---------{---- �� io= Distance to nearest: Wel!_____ _� ________ _____________ _____Foundation__ { p� .,. ---Prop. e------- ----------------- G' ; Lin G LEACHING LINE' [ ] No, of Lines-,-.__ ___._____- :.Len4.nf ea line._ V� " ----------- ----Total Length,_.. �� -- ---- _ #Type -Depth Filter Material-----J/ /� ------ ---------- }D Box-- _____---_T a Filter MateriaYF _ --- / �- p p C�'------ ----------Property Line.`Gt ------- 4 �( SEEPAGE PIT [ ] Depth ce to riea Diametelr ---._- __Number----------------- -----' Rock Filled Yes❑ No ❑ 1 oundation- .,. Water Table Depth.. - --'_------------•------'-----------Rack Size----- ---------------------------------- i REPAIR/ADDITION (Prev: ance to Peamit#Well________ f- -------------------- Foundation c___-_`---------------- Line-------- ------ ---____--. [ = --- -------- ------Date---------- Prop. Septic Tank I(Spe?cify'Requirements)__________________�° --_,: 7 �. ..__ ---- ---------- --=------------ -------------------------------------------------- Disposal --------------------------- ---------------- -- i IS O5a Fle _ 1 p - (Specify Requirements), ------------- -------- l---------- ---------------------------- ----_ ------- ------------ ------------------- ------------------- .7 � ----- -- --- --- - --- = - � (Draw existing nd required addition on reverse side) I hereby certify that,I have prepared #his application a64 that the,work-will-be-done-in accordance with San Joaquin County Ordinances,p State Laws; and Rules and RegulatI6 � of the Sart �Jocquin Local Health District, Home owner or licensed agents r ..,. g signature certifies the following: "I certify that in the � '—"1 performance of:tfie-work for �whi^th,.th'f<is permit-is-�issued,I--shall-not-employ any person in'such manner.as to become subject t Owor an's ompensbti an. lawn of California. ! r s, Sig ned. _. . - , �: Ti ,. Y - --- -- ner (If other than- owner] •��--J� - � ( � � FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED-BY---= .- - DIVISION OF LAND NUMBER-- ------------ ATE Y ---------- - ----- ADDITIONAL COMMENTS = = - 1 f = - ___________________ __ ________________________ _____________________________________________ _.__.. - 1 i ----------------- ___-------_---------------------------- __ ^Zz �., _ _ / ------------------_____---_.-__,________ _ 5 _ ----._____--- _ -._-_---.--_ - 1 — --2 -- _ --- - - ------------ __._._ __ ___ --------------- Final -_ ._ Final-Inspection by--------- ----------------- =- --= ------------------------- EH ` -------- ----- 'EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M