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f FOR OFFICE USE.. --...... ------. .......... .............. APPLICATION FOR SANITATION PERMIT FOR LONC;t: Ubt ............ : (Complete in Triplico#e1— Permit No7 " ........................................ . . . .. .... .............. .......... This Permit Expires Z Year From Date Issued Date Issued. r p I Applica on is�iereb"y made to.the S n Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance with County Ordina a No. 549 and xisting Rules and Regulations: I 1 f a , JOB ADDRESSAOCA I N ..... NSUS TRACT...O45Z5_-- P30--• -4 Owner's Name.... ...................... ••--- Address_.....,-g ......._... .+. .......... ......_. ..........City . _ . .. ...........-- Zip-:.:....------------........._ . Contractor's Name...-_ ........... _ License #..> _ ....__..Phone.......a /�....... `. Installation will serve; Residence ❑ Apartment e House [:] Commercial Trailer Court C]Motel ❑ Number of living units:....... .....Number of bedrooms--.._f...Garbage Grinder............Lot Size................. ......... ...... Water Supply: Public System and name..................... .... . ....._..Private A Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat` Sandy Loam ❑ Clay Loam ❑ �r Hardpan ❑ Adobe❑ Fill Material....... . ..lf t9es,type__________________._. {Plot plan, showing size of tat, location of system in relation to wells, buildings,etc, must be placed on reverse side.] ! NEIN INSTALLATION• (No septic tank or seepage it permitted uS lisewer is available within 200 feet,) ' p p � p � f PACKAGE TREATMENT f ] SEPTIC TANK I 1 Siz �� Liquid Depth. -...... it Capacity.)�p O v.------Type 1�Q...- Mote�rial--_ .' � �_._-__No. Compartments.........:.a A_......�.._i Distance to nearest: Well. - -.--�............ .....Foundation. .....Prop. Line_. �.. LEACHING LINE ( ] No. of Lines................... .........Length of each line..............................Total Length ............................... 'D' Box_...........Type filter Material_- .. ...........Depth Filter Material................................_._.._.....:-----...... ! Distance to nearest; Well............................Foundation............................Property Line...................... -_-•- I, SEEPAGE PIT Rock Filled Yes ❑ No .� ( ] Depth ....................Number ._.....------•- Water Table Depth....................................................:...Rock Size...------...... . .....----- ------_... � Distance to nearest: Well---.............. ..Foundation..........................Prop, Line............. REPAIR/ADDITION (Prev. Sanitation Permit#.............. -------------*.. .............._Date......... • -- ----_-. ,; Septic Tank(Specify Requirementsl................. . . Nt Disposal Field (Specify Requirements)- .. .............-- ........... .... ...............•----------_ .. ------- (Draw existing and required addition on reverse side) a 1 hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin Count t Ordinances; State-Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agent!;. signature certifies-the following. "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner its to become subject Workman' om ensat€on taws of California.- on Signed------- ---------- �. _.'"- �r..... Ctwner By.........: .......:.... 4- o� .. ._._...._...--.Own Title.. �� -------- ...... ...................... (If other than owner) F OR DEPARTMENT USE ONLYTf APPLICATION ACCEPTED B . .. . ... .. .......... ...................................•-•- ....DATE . r /77777_1 DIVISION OF LANDNUMBER------------------- ---------------- ---- ..... DATE..... :._ ADDITIONA ....L COMMENTS_........ ........_........................................................ ... . 1' .. . ......................................................................• ............... ---....-----......._........................- ...... Final lnspeciian by:.._... � ............. EH 13 24 SAJ AQUIN LOCAL HEALTH DISTRICT FRS 21677 REV,7/76 3M ' r