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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .. . ....... Permit No...7.1.... .�.. (Complete in Triplicate) --------------------------------- ----------- i; � �� Date lssueds'. '3"?�-- :......................... ----- . This Permit Expires 1 Year From-Date Issued . w Application is hereby made to.the San Joaquin Local Health District for ❑ permit to construct and.install the work herein described. This application is made.in compliance with County Ordinance No. 549 and existing,Rules and Regulation' JOB ADDRESS/ Y- .5F'40„ � - • LOCATION....__ � _ V '----".CENSUS TRACT......---•---•-- ...... _..... Phone .... ----- . Owner's Name------ 40 -- ...... .. . ..-- f' .... .. - Zi ----•-.......- --- Address--......... --------- ------------- -- ---- - -:... City p `' License #JQ^ /..... Contractor's Name. ..... .. . ` .. _. Phone... . Installation will serve: 'I Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Ai . Motel [] Other...- -... . .. . ------.- Number of living units:.............".Number of be.drooms. ..........Garbage Grinder. Lot.Size._ !� - vat Water Supply: Public System and name-------------- --- --------------- -------- ...... Pri e Character of soil to a depth of 3,feet: Sand EDSilt ElClay ElPeat ElSandy LooM-V Clay Loam [I i Hardpan ❑ Adobe❑ Fill'Material.. If yes, type-------------- -------------- 41 (Plot plan, showing size of lot, Potation of system in relation to wells, buildings, etc: must be placed on reverse side:] .P seepage p p ttedif pubTit sewer is—avail—able lakile within 200 feet,) NEW ' • ' C NEW INSTALLATION: (No septic tank or see a e it ermi PACKAGE TREATMENT [ ] SEPTIC TANK [ ] `Q•.------ --' "`"�Li�quicl"Dep,t�Ff]"r .=- -4) Capacity).( �Q.----..Type. ----...I Material... - No, Compartments Ch...." Foundation -- ------ ------Prop. j.jne-------- --- - --- --------- Distance to nearest: Well._ . --... . SII LE E 1 No. of'Lines ...... ....2....------..Length of each line ---------60--------- Total �. -------- i is .� e D' BoFilter Material----------------� ----� YP Filter Material,s�, J'LA.JDepth - f ----- Property Line------------------------------- - Distance to nearest: Well----0a--.� ---...Foundation- SEEPAGE PIT [ ] Depth.-- -- ---------Diameter----.-------------- Number.._._.------• ------------------ / Rock Filled 'Yes �] No❑ I n Water�Tab€e Depth.-----_----- --- - ---.Rock Size.-.- i t Distance to nearest: Well----------------------- -------------------Foundation-- ........... ........Prop. Line....... -------- -_ ;i I REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ..........Date-------..------------------------ -----) i Septic Tank (Specify Requirements) / - - ------ f ------ . ----- - ---- Disposal Field (Specify Req uireiment ).. " ---...... 1, -.... ... ..... 0 if .......... -----------------_.................... ........................ . -------------------------••-•---- i' (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and' Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed •agents� signature certifies the following: ' "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's CCm&ensation laws of California." Signed Owner By------.... M- 10 -- -- Title --- ... f the t n owner) fl FOR DEPAR MENT USE ONLY q DATE .------- APPLICATION ACCEPTED BY--`!... i✓.. . .1 .. /. ... ` DIVISION OF LAND NUMBER.•"......---- -- .. ----... DATE---- - --------------------- --- ---------- ADDITIONAL COMMENTS......i------------ ----- -- -- ------------------ ----- --------------- il ii - -------------------------------- = _;: ------------ ---- ----------•:--- -� -...------ -... -•------••--�--------- ---- � ��:1..�"7 - - ..........__...... Final-Inspection by: '� EH 13 24 SAN JOAQUIN LOCAL HEAL DIS CT F85 21677 REV. 7/76 3M