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FOR OFFICE USE: PFk�FFIZE v + �SE: w+ /I �� PPLICATION FOR SANITATION PERMIT �� 1 (Complete In Triplicate) Permit No. This Permit Expires 1 Year From Date Issued Data issuedze"- -. 7 Application is hereby made to the San Joaquin L a� Health'Distaict for b permit to construct and install the work herein described. This application is madee �artte w'th,Coun Ordinance No..,5 and existing Rules and Regulations: JOB ADDRESSILOCATIO," _ �,: I _.__..�•�'LJ _ 1 - -..-.._ �/ .---.---.CENSPh TRACT I Owner's Name / -------- -------------- one6 ' 7/-. f 3r a• - -- Address ... City ........... - -Zip--. . t i Contractor's Name.N- � 7`. --,-License #- , �___.Phone. Installation will serve: Residence Other'/House� Commercial F-1 ,Trailer Court ❑ ',f M te ❑ '� ..� E ----------- ............ ...:.....:. � �S' Number of living units:... .......Number of be Grinder... Lot Size._.. Water Supply: Public System and name`..-. _.. .._t1- ",_- ff ; ! �` --- --- _ -------------- Pr'Iva _ to Character of soil to a depth of 3 feet: ')Sand E] I -Silt❑ Clay Peat❑ Sandy Loam Clay Loam ❑ I Hardpan E] !Adobe❑ Fill'Material jr.`Fy If yes, type.. ........ .... . .......... i I (Plot plan, showing size of lot, loea,tiori:of system in relation to wells, buildings, etc. must be placed on reverse side.) I f • NEW INSTALLATION: (Noseptic' tank or seepage pit permitted if public sewer is available within 200 feet,) i I T 1JF 1� �taI1 I' 'NPACKAGE TREATMENSEPC TANKKi ISiz 'e `: ..Liquid Depth.o---------- I�) ------------ M" ---- --- ' Capacity;!.!,✓' ( !Type ate,' -.Material-. .-----No Compartments ------------ 4 Distance to nearest: Well__ 't`--------_.-.:-..._'_ ''foundation. _��-�---� Prop. Line.._ .. _ �• LEACHING-LINE- , `No:of Lines_.i.�.i F '» i _ ".Len thf,ea i, line._ ..Dp.: ^_,_. _ _ Total Length ._.. a� D Box_ ..�.-.__ Type Frlter.M trial._ - ---Depth Filter Material .___` ..... ....... ._. :Distgncc�to nearest: Well.... -, "__ ?�•f_ .....__ .-:. _..,Pro Property Line P Y - SEEPAGE PIT Depth -•�- --".'. Diameter..__ �: ._'.. t_�Lr Num�' ber--,----•.---.-•---------- Rock Filled Yes-E] No • Water Table,Depth.-._--A_- -- 1? - Rock Size - ----------- Distance •----Distance to nearest: Well.. ^• rj - �-- -------- �_Foundation_...-._....._ .----Prop. Line---- -------- -----' J REPAIR/ADDITION (Prev. Sanitation Permit#_ ......- __:..... - - pate_"__ ) _...._ . .... ---- Septic Tank (Specify Requirements)...—.......... ... f - - •-•.............._-.._...---•---- k Disposal Field (Specify Requirements)- � ........ ----------- -------- 1 ' 1 -_.......................... - ' {brave existing and required addition on reverse side) I hereby certify that'I have prepared this applicaiian-and-that-the -wor-k-will--be-done. In accordance withxSan Joaquin County Ordinances, State Laws, and Rules bnd Regulations of the San Joaquin Local health District. Home ow r,or licensed agents signature certifies the following: �J ti4 "I certify that in the erformance of the work for which this ermit is issued I shall not em to an l P p y y person in,such manner as to become subb*e Workman's//;C penso on laws of California. Signed_,��.(.5.�- -&-44"_ . .P�I BY' = ...... = -. . .... e 1 (If other-thra�n owner) �`'N F+0R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY t " .. .. - •----------- -..---- •----- ::.....•_ DATE..?. " '= DIVISION OF LAND NUMBER: .. ._- 4W ............•-- DATE - - --=---.....- --------......_.t... -DiTbNAL COMMENTS_..---- ....•..__.._. �,-•._.... 'Y' ------ -------- -- --------------- -------- ----------. . - Final Inspection by: _. _ _ - . ._.. ------Date lip EH 13 44 JOAQUIN LOCAL HEALTH DISTRICT F&S 41677 REV. 7/76 3M r a