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-30 FOR OFFICE USE: FOR OFFICE USE: . APPLICATION FOR SANITATION-PERM - _ Permit --- ` (Complete in Triplicate), ., P o•- e. Date issue 7_2 _ _ _____________ -- --------------------------------- - - -------- This Permit.Expires 1 Year From Date Issued constructto Application is hereby made to the San Joaquin LocalOHrealth DisNo.trict for a d exis permit This application is made in comt ng Rules and Regulatithe work herein described. Regulations.pliance with C u y 4 J- �.�- '�------- CENSUS TRACT------ ------------------------- JOB ADDRESS/LOCAT ON._ ._ t a _ - -------- owner's --=--- ----Phone__-- -- ---- - - - - ----------------------- - Owner's Name ----- ----- - t City- Address --- -------- . � Z i i/ 7Lk- 7 _ Address ---- o � License #_ 71 Ph ne_ Contractor's Name------ -- Residence Apartment House.❑ Commercial ❑ Trailer;Court El , Installation will serve: ' _ _ ... Motel ❑ Other------- ------------ --------- ------------- I , Number of living units:- 4—Number Number of bedroorns_� Garbage Grin t Size.__._------ r`� ---- _:--Private El Water Supply: Public System and name-___:-- -- Peat ❑ Sandy Loam ❑ Clay Loam ❑ Clay e - r Character of soik to a depth of 3 feet: Sand ❑ .Silt❑ Cla ❑ ; Hardpan ❑ Adobe FiO Material------------ yes, type ` (Plot plan, showing size of lot, Iocafiion of system in relation to.wells, buildings, etc. must be placed on reverse side.) } - ' NEW INSTALLATION: (No septic tank or seepage :pit ,permitted if public sewer is available within 200 feet,} ' Size --------Liquid Depth--------------------- ----- ,. PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Capacity TYpe------ ------ ----- Ma#e�rial�---- --:- =----=---:-No. Compartments----------------------------------- � p Y ` Foundation: -----Prop. Line- ----- Distance to nearest:.Well----------------------- -- -- - tLen th of LEACHINeach line---------------- 7--_ ---------Total Length ------- -- ------ ------ ------ G LINE [.} No. of Lines----------------------- ------ g f Box -Type Filter Material: Depth Filter Material------------------------ ---- --------:---- k D' ,,- Property Line ------ ----------------------- Distance ---- - ------------- r Distance�to. near.est: Well..---:---u--.z--.----�-s------- F-oundation: --.--:------------- . Rock Filled Yes N SEEPAGE PIT Depth --------- --------Number------------------------------= = ❑ ;. ^� Water Table Depth- -----= ----- ------ ------ ------ ------ ------RocSize---------------------- ---------- ,----- -- --- -----= ------- ---.- ------- k - ---- Pro Line---------------------- --- � Distance'to nearest: Well.___.__ --_--_-� -------------------- Foundation----- p __.Date -- --------------------�------------------ --1 , 4 REPAIR/ADDITION (Prev. Sanitation Permit#--:----------: _ ; _ ------ --- Septic Tank.(Specify Requirements)-" ___j -- -�-=--- --------------- --- - r _� ------ :_ Disposal Field (Specify,Requirements):_._-, - 'r -----+--- r - 1 r J ------ -----------` ------------------------------ --- _ ------ -- --------. ----------------------------------- '"--- ------ r ---- -- . ----- - - ------- -------------- -- _------------------------------------------------------------ ------ -- _ S - . J (Draw existing a d required addition on reverse side)in:accordance with San- I hereby certify that I have prepared this application and that the work will be done Joaquin County Ordinances,. State Laws, and Rules :and Regulations of the San Joaquin Local He 1th District. Home owner or licensed agents signature certifies the following: "1 cerci that in the performance-of.,thework for which this permit isoissued,-17shall not employ any person in such manner as to beco ub'ect to rkinan's. Compensation`laws'of California.' _ e ,_ A A : 4 Owner-� Signed - _. .-._-: _� ------------------ --------- Title--- F - = - k ;. BY ---- --------------- ---- _ , t { (If other than o er) FOR DEPARTMENT USE ONLY - -------------------------- DATE ---- $ ----------------- ---------- APPLICATION ACCEPTED. BY ----�'f1l ----------------------- - - - �; ----- --- - -- --- - - - -- - DIVISION OF LAND NUMBER-------------- = : - t - --------------------------------------- --------- ---------------- � ' ADDITIONAL COMMENT ------------------- --------------------- ---- -- -------------------------- -. -- ----------------------------------- ------ -- --------------------------------------------- ---------- --- - - �- 11 Final Inspection by,.--:---- - F&5 21677 REV.7/76 3N EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT