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_ FOR OFFICE USE: FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT r , ! C _.• 6 Permit No:/.7- . "...----.•--•---••-----•-- - ..... ...... ... .. - � (Complete in Triplicate)...—' ? �! Date Vssued..�r..,13:7 - p This Perini Ex ires 1 Year Fr m Date issued hereby made to.th -----------------••--------"-- l the Application is he y 'e San Joaquin Local Health District for a permit to construct and instalions: work herein described. This application is.made in co I'ance w' Cou t O in Oc No. Q and existing , es a u�c 1 � ., s • /�.0/--- � - -----�----- -�� --� � - - - - - ----- - ----17 ---..:"-C_-E.N.".S-"UPShTRACT_-- RACT. .. .-.-.. _.�•-----.3-.-.-. ---- --- ---""". JOB ADDRESS/LOCATION. - ---------- Owner's -b--• .._..� . ' Name.. .. ---- .-Zrp � `�` i ...... City- • - Address .... , , ) Phone.��-�4� "" " ....License #�-•f .�. .-�-� s Contractor's Name_" ----... ..- , Installation will ser Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ n Motel ❑ Other..................""". •----- Number of living units:._ "- . - ._Number of bedrooms.`- d,*...Gar age Grinder-. -Lot Size---•-- Water Supply: Public System and name" - " u�o,��c�"`::-.: - .Private San Lo fClay Loam ❑ f� l Character of soil to a depth of 3 feet: Sand ❑ Silt❑' 'Clay Peat ❑ K y Hardpan ❑ Adobe ❑ Fill Material If yes, type"�r"--1.--�-. "" ' " k {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.( p it permitted if public sewer is NEW INSTALLATION: (No septic tank or seepage p` p p available within 200 feet,} Size. . . {x - Liquid Depth. L PACKAGE TREATMENT O SEPTIC TANK [� � ---.--"" -- F w+" l Capac! y Material .-- -- •.No 'Ca artments...------• -----•- I,S tY Type/ t. Il x -.. Distance to nearest: Well-.""- ' ------Foundation-...�. __ Prop. Line-.f- Q . .-.._...." LEACHING LINE [ j Not of Lines .1 ---"" """ Length of ch line.-"--... IN iTotal Length .. ... 'D' Boit -Type Filter Material/� Depth Filter Material..� � OHO+ PropertyLine--... /----- "--- """--- i Distance to nearest: Well - `�-- Foundation--"-_�"4- ------ os l Rock filled Yes ❑ No SEEPAGE PIT [ ] Depth!.......:...:...Diameter"_.--..------- ....Number..". ------- ------------- •- .. , rpt•.-�'"' ( -•� - Rock Size----..""` -`'" Water, Table Depth.------••-------•--�---.-- �i Pro Line.. "". . -- on- .. -. ;gyp. Distance to nearest: Well ------ Foundati kREPAIR/ADDITION (Prev. Sani.tuation Permit#.--------------••---------- ---- -- --- -- Date.... -- -� !.,----k-.--------,,:•f-`- } .. -- Septic Tank (Specify Requirements)"--.-- " ---.. .-- _--- " .� I Disposal Field (Specify Requirements)---------............. -.------ --- ----, -- °- -:- � ----- ------- --- . -- , _ ,, \9 ---- ---'-"-----'".-..-:_-""".--"-""---------------`----"------- -".`----"-----------------I-----•-"""." "._ ..11 -' --"-"._...- - i i (Draw existing and requiredaddition on reverse side) certify that 1 have prepared this application and that the'%work will be done in accord tome ow with Ln orJVicensed agenquin ts I hereby c y Ordinances, State laws, and Rules and Regulations of the San 'Joaquin Local Health District. signature certifies the following: i " thapr which this permit is issued, 1 shall not employ any person in such manner as I Certify t in theerformance of the worts fo k to become subject rkman's mpenpation laws of California." Signed. - Owner --- Tit e.- -.= ..." - - -- ----- ----- -".."- . .................. ... -- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE .3 �e�-- -- -- ---- .._....DAT --_-------------- DIVISION -- -- --- - DIVISION OF LAND NUMBER.....----- ADDITIONAL COMMENT - /y 1� ,�t.I� ki�,�r_"�-Su,#a.N"".•�!.li +" sx5l -_'yam---�" s ��--` "' ..-•------=- r �.r Via•,Ga '� ----------------- - -- - - Date --- "-`�Y.. Final-Inspection b ..'r----- - - — ........ -.-..."- --•-- - ---- -- - - - F65 21677 REV. 1176 7 1 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT '