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FOR OFFICE USE: ✓ 4 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.-PF_/O Date Issued_1_I--3a-�� -~ ---- ----- 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 in compliance w't County Or an o. 549 a d exi in ules and Regulations: i S TRACT-------------------- JOB ADDRESS/IOCATI � ..CENSU : Owner's Name_------------ -'- -- ------ - ----- ------ __7-------------' = --------- ----------- ---"Phone----"-- ----------------------- Address-_-_- • _ - - Contractor's Name._:__. l!- r -- ---- �_; r_, License #--- 1-Phone_ ' ��- - t g.. _ .__ Installation will serve: ) Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ , _ .. .__ ,.. ._ -Motel ❑ - -' Other------------------ ==` �_- Number of living units:,_ .__-[,__.___Number of bedrooms_-..-'?------ Grinder Lot Size i _. (/ } Water Supply: Public Sysfem'and name----=-----------:.--;------ � -------�,-:--------- :_- ----.�- ---- :. ------- ------------------------------------ Preva F -- te� Character of soil to a depth of 3 feet: Scrod ❑ Silt Clay'A❑�-,Peat❑ Sandy Loam E] Clay Loam ❑ Warclpan ❑ 'Adobe - ill Mate ri�xr- ,-_v-If yes, type----------_---- __-_________"__- I (Plot plan, showing size of lot, location of system in relation to'welis, buildings,:etc. must be placed on reverse side.) ' NEW INSTALLATION: (No'septic tank of seepage":pit permitted i# public sewer is available within 200 feet,) / PACKAGE TREATMENT [ ] SEPTIC TANK"' M __-__ __-_-- _____ w__"-"___ € 1 D h.__ _---Lqud eptCapacity _ _ __:.TYpe' '- - aterial__ - ICompartments__-_.�__----- i } Distance to nearest:,Well-=.____, �______"_____-_____------ F n atio .-_�-----------Prop. Line___ _ LEACHING LINE: [J,]/� r.___-_,. Lent f each line._, No. of Lines_ g _ __ _ -------Total Length.__. ,____ _ D' Box__ �T e Filter Material_ �_ _ Type Filter Material ---------- Depth Distancato nearest: Well____- foundation--- _---_."--------------Property Line...-.oar.-_----------------------- _l , / , ,.._.._.;.... i.r.s .�... a._. i..... SEEPAGE PIT De th_ _ � _Diameter ' 9 p Number__' -- = ! Rock Filled Yes.[;R_�0 [ 1 Water Table Depth. Rock Size' �_ _... _ -7._/ 3 _0 ` Distanc6':to nearest; Well- __/4�------.-----------,_------Foundation-- ------_Prop. Line---- -- v � t REPAIR/ADDITION (Prey:Sanitation-Permit#-. ----------- ------------_ Date-------------- ----------=----- - j - Septic Tank (Specify Requirements)----------=---------------' _ '_ - ---- -- -- _--= ` --------------------------- Disposal Field (Specify Requirements) : --------------------6---- --- - ---------------------------------------- -- � . } p ting and requi ----------- ---------------- -------:---------------- raw exis ------ ----- :fr`r ` ------�-- f red addition ori reverse sides i t .. (D . 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 RegulationsYofthe,:San # qyi Local Health District. Home owner or licensed agents - signature certifies the following: -T - t "I cern that'in -the certify peir4orm6nce of the work for'wlii h tl 1s"permit is-issued, I 'shall not employ any.,person in such manner'as to become su ct o Wor ma s _.0 pen anon I of,, lifornia." ' Signed__-_ -_ - L� �- :ems- . By. . r ------ -- Title-- - `' -- : w. : (1 other than owner( ` FOR DEPARTMENT USE ONLY • APPLICATION ACCEPTED BY_~----------- ------ --- ` = - ------------- _----- ---DATE.--- -----Vk- DIVISION OF LAND NUMBER------------ ---------------------- -------=---------- -- ------- ------------------ ------------------.DATE------ ---- ---- ---- ----------------- ADDITIONAL COMMENTS-- - _ -= - --- -r ---W- - ------------------------------ ------------------ - - ----- --------- Final Inspection by:' �7 _ ------------- -------------------- ---- -- - ----------- ---- Date".. ��r .4 EH 13 24 SAN JOAQUINp LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 31/ f