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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE. (Complete in Triplicate) Permit o.�. _. .S�l� D I s�d ........./.17 This Permit Expires 1 Yea FI<.enl.Mate Issued• FIL J 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 Ordiponce No. 544 and existing Rules and Regulations: ? ..._ �,. r JOB ADDRESS/,LOC. . N` ``7 ' } ---- --•--------- s CENSUS TRACT-. `s I Owner's Name..-/:." . �- - -- Address77_. t C Zip--- .•---------- ... - -- Contractor's Name-_..... _ .- -:------ ........... ..License #_, Qcs7.•?� d/ ,,,��r',�3 Installation.will serve: Residence " ' i . [ Apartment House❑ Commercial ❑ -Trailer Court ..- .�.._ Motel ❑ ;Other.;--------- ....... Nu' units:........... Number of bedrooms.., .__Garbage Grinder............Lot Size i Water Supply: Public System and`name.... .....:........................ . _` -.. . -: --•--=........._.-.;.,..... -:: -..----- ' � --�--�----------------------:--•--..Private Chdracter of soil to a depth of 3 feet: Sand Silt -Cla ' ❑ y - � 1�Clay.Loam ❑ l e ❑ ❑ �❑ Peat Sand Loam [ r. : Hardpan ❑ Adobe❑ Fill Material....... ------If yes. type--------------------------�,:..: (Plot plan, showing size of lot, location of system in relation to wells, buildings,etc.must be placed on reverse side.) NEW INSTALLATION:" '(No�'septic--tank or seepage pit pe�mifted if public sewer is available within 200 feet,} ` PACKAGE TREATMENT ( ) SEPTIC TANK [y-- Size:...- 'tl'S-14'F% _ liquid Depth. "_ + Capacity..... 04 -..Type-,.. =Material,_.T: Nor Compartments_' . (0D` 6 i 1 .. - I ------------- Distance to nearest; Well-;..w•.:_� 5. Foundation_ ----:--. _ ._.,..:.: Prop.-Une_ LEACHING LINE No ' f i• �" r ► ` .[,;Y-• o-•Lines_: ::.: w,-Length of ea � ris. dQ4e l� ! ; •. - f .t �� --_--------: a Len th.--f•------ ---------- Tot •- - _ D' Box.l. -Type Filter Materiall`r-AY __•_.V` pth Filter Mdterial....._- e { i " r r.f Distance to nearest:Well---_-_�.f. ,_-_----..._Foundation----- -5----------------.Prop " �_ _Q > e lee: •...... • SEEPAGE PIT '� Depth o7_ --Diameter.-••• ---- lti9umb r -----=---• _- Rcii k Filled�Ves�- Na❑ Water Table QeptF► ----i------------ ----------- Rock S'rie: 1 r Distance to nearest: Wel I_r'_-fl_d--i -------- _:-- -------Fotindation.11------- '_.Prop. Line--L/-5 v_ :.. PARnkDf (Prev. ein �ek..r.---i-t#.I.- ---------- #. . --------�'" - --- -•-I1 --=---------:`------.Date:.----- SepticTa (Specify ml _ :•: :'�:-._.----•---------------�) -;: -------------------- :.... Disposal Field (Specify Requ.irem�nts)...................•... ....:--..___ . , ------------------ --------•--------------•------- ---------------------- - --------------•-------------...--------- •---- ::----- ---------- ------- ............ ----------------------------- -------------------- ... •! q - - = -------------•-------- ----_ .-_-------------•-•-••--------- (Draw existingand••re'�VFM'4ddition-on reverse side) 3 I hereby certify that I have prepared this application and that the ierk will be -done•Inacco►aance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of:the, San!Joaquin Local Health District, Hoene owner or licensed agents signature certifies the following: ' i "1 certify that in the performariee aCflie'werk for which -this a ok is issiisd F'shall not ein la an P • p Y Y person la'such manner as to become subject Workmanompensation laws. of California." . .. Signed-:.••••_. -- •• .---•=-----•_-- ------ n --------- ---=-------------- er . Tit - (If other than'.%%,ner) ' - •` FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED' BY._--- _ "- ----------------- ------------DA ADDISI ONAL LAND NUMBER:....w - ....... ----------- .........' -.... _ ... DATE:- - COMMENTS_....-- -_ __ } : ... ----•.----• -, --••-•--- ......... . .... . c. ------ ..............•_•...........------- --- .-- - - _ / - - Final Inspection b Date: ' . _. -_......... �S s� SAN JOA IN LOCAL HEALTH DISTRICT Fd5 21677 REV.7/76 3M