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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ---------------------------------- (Complete in Triplicate) r?f6— i° - -------------------- ------"--------------- -- This Permit Expires 1 Year From Date issued Date Issued_?_-1!7 6 - k � r 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. / �' e -' -'-- _.,. CENSUS TRACT------ . I Owner's Name------/W-1 i -L -- ----------- ---------------------------- `------------ hone Address citylllwxrUlcc,q / �p i - ----- q Contractor's Name � G _/ - = ! r, Z -- ----' -----.:License #�1�.�_�r�---Phon _ ___ __ ' Installation will serve; 1i Residence ( Apartment House.0 Commercial ❑ Trailer Court ❑ F ;l. t....:.y Motel ❑ Other--------- ----------------- - '--------- `------= t Number of living units:-.---/..--_--- of bedrooms_- _.__ _ :_.__Garbage Grinder__._.__..___Lot Size--------- -------------- a`ter Supply: Public System an 0 ---. -_ Character of soil to a depth of 3k - ----------'-------------- ----- ----------------------;----------------- -- -----------------------------------------Private � fi p feet: Sand ❑ 'Silt❑ :Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ Hord an` "^*Adobe _._ .'.._ _. o # P ❑ : Fill Material --------If yes, type--- ----- ------- -------------= t (Plot plan, showing size of lot, location of.system in relation to,wells, buildings,'etc, must be placed on reverse side,) NEW INSTALLATION6 '(No,seg tic tankYor's'ee a e [ l P. p g pit permitted'if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] S C TANK' ..0 ] Size. .r — c ' d D aterial__- ------- No. Compartments- -- -- - ---Ca accty------W--:---i-- M " u � t ,. t -------- --.Foundation-._._.: ----- --- --•Prop. Lin e---- -- •-------' ['] NotofcLinesnearest- Well.. Length o i LEACHING LINE: ' f each.liria---------- ---------------r=---Total Length.----- . --- -- -= D' Box:------------Type Filter Material__--------------------Depth Filter Material--------------1. ------------- 1. ------- Ris a}to nearest: Vl/el! --------- - . -- n . ' ., . . L -- - ----- - ] --,.... . ,.. 9 to d o _ - f d ti ii SEEPAGE PIT [ P -' ---.-Diameter_: '- Numbet.L f f t P k II [ l De h_ :.... r :---Property Watel'�Table Depth.. R----- : . z Fi Y e� � es❑ No - ,-_ Rock Size 1 Distanceito nearest:Well .._ + g F Founda#ion._ ------------------- Prop. Line s l REPAI DD1TI0 1?rev:Sanitation Permit# _ _ __ _ ! a to: fy Se tic Tank i _._.__. .. r,`4 ] Dis osdl Field P(SpecifyI e Requirements)'.---- z_lr � , = ------ f • l--- ----------- = = ----^---�--°G I -------------- _-_ i {Draw existing and required addition�on reverse side] f I hereby certify that-1 have prepared this'applicatio andthat thy` work will"•-be, -done•in-•accordance with Sani Joaquin County Ordinances, State laws; and Rules and Regul ti ns of i t_he\Sari Joaquin Local Flealth District, Name owner or licensed agen signature certifies the followi g: L f "I certify that in the (serformdnce of the work for'w_ {hstis,; erm�t isissued, I shelf not employ any person such manner as _4 to become subject' W man om ensation_laws..of..Calyf nia..'.`� a Signed- x � --------- -------------------------------------- .. Owner lj * ' -- ---------' ------------------ =Title:'- [ _ (If other than.owner} t ! ; FOR.DEPARTMENT USE ONLY' : � _t t APPLICATION ACCTED_BY _ ----- .. -L DIVISION OF LAND NUMBER j - --- --- -------------------------------------------------- DATE_ ---- ADDITIONAL COMMENTS-----------'�-"- -.--- - - r i -- ----- -- ------------------------- - '^� -- ----- ---- ----------------------------------- '-- - --, - - ----------- --=-------- - ----- a Final Inspection by = =' - , - �_._,w 1 EH is za �. _ ---- -- -- Date---- r' SAN JOAQUIN LOCAL HEALTH DISTRICT': F8s 21677 REV. 7176 aria .