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R OFFICE USE: FOR OFFICE USE: { FO APPLICATION FOR SANITATION PERMIT - �". 3 p ---- --------------------------------------- - - _ (Complete m Permit No. `d' 7, ►' p � Triplitatel - - ------------ --------------- ---- ------------------ Dote Issued__f-.&-e;��K This Permit Expires 1 Year From Date Issued 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 i compliance with County Ordinance No.R549 a dexisting Rules and Regulations. 9 f J ' -------------CENSUS TRACT.---_- - ----:------:----------- JOB ADDRESS/LOCATI - dW --'-----`-`- _ - ------------------ ------------Phoney.`-- ------ ----------------- Owner's Name / ------------------------- P �-- -r l ---------------------- Address-------------- ------ - Q- ---"- { f J ,. Contractor's Name-----'---: Lc1LH ""�' License,,#_P------ -Z"---- Phone---- ------------------- } --- l Motel Other-.-'__- Commercial Trailer Court ❑ �+ i Installation will serve: Residence � Apartment House.E] vin units:........ . ......Numb r of�bedroa❑ms_._.- :_ ge Grinder-. .-__.._y_LotSize I i Number.of living �_ �---Garba Size-------- ----=--------'- '------ --'-'- - -----"- -' Water Supply: Public System and name--------- --------------- . ___.Private Character of soil to a depth of 3 feet: Sande7�., ilt❑ Clay ❑ l Pea�E] Sandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobe [Fill Material_-._s__-..-Ifys,4type'-- -------------------------- t a _ � _ ° , i [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc..:mustfbe1 placed on reve-rse�side.I NEW INSTALLATION: (No septic tank or seepa a pit permitted if public.sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ Size----- -------------£----------- ----- --Liquid Depth -'--____------ !No:- - -- r Capacity--- d-d. Ype No:Compartments. Distance to nearest: Well-...... - _ :_�---'- - Foundation_- _- _QJ -Prop. Line-- --- ---. . -__.t_er tth of eac-h'line------- -2- g LEACHING LINE [� No. of Lin_es..,--t_-_ ' " " g L2S_ _�.._Total.Len th --------' _a__ ----------3_ D' Box-----!_-"_Typ Filter aterial - -----Depthi Filter Material--------- --------.------------------ -----------' - --- Distance'to nearest: Well -�Q_______ _.__.Foundation_.-___�-L]__..._J.______.Property Line__________________ -_ - e/ 5 _[ ' Rock Filled Yes [eNo SEEPAGE PIT L` ] Depth.- r�iameter_-____ ------Number__,_-_- - Water Table Depth �C'I.-t -------=-:-- Rock Size_.; 6 `/�----/� ----- ------------ t. }} Distance to nearest: Well -147P.-K- ------------Foundation-_.t___�..Q_�--1 -_..Prop. Line-_ K __ (Prev. Sanitation Permit#-'-:----='------=---- ------.Date___-- 4_,.._-'_.--------:-------------------- REPAIR/ADDITION Septic Tank (Specify Requirements)___._',__-----:----- l�`' ------------------------------------------- -------- I Disposal Field (Specify Requirements).--------- --- ------,'--------------' :----------------- -------- r4 - = - - J � (- ____________________________---------------- ____________________ -.. ------------ = :_ E ---- ----------------------------------------------------- -------------- (Draw existing and required addition-on reverse-side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin Countil— Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health. District, Home owner or licensed agents signature certifies the following: i s "l certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as Y to become subject to Workman's m enscition la s of California." ' Signed " " ner �.. reC ---------------- �� (If other than owner) x FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE DIVISION OF LAND NUMBE ---- ---- :.DATE ---------------- ADDITIONALCOMMENTS------------------------------------- } = .-----------:---------_-- ------------------ -------------- ----------------------------- r - ---- --------------- --- - --- - --- - - ----------- -------------- ---- -� -� --- Final Inspection by: a ``p¢ { � " Date-------- ------ ------------------- EF1 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M *a-