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t FOR OFFICE USE: Y APPLICATION FOR i SANITATION PERMIT ORr.01 FICE USE: (Complete in Triplicate) Permit No.-.--- r - ----------------------------- 1, .7 This Permit Expires 1 Year From Date Issued �` ' ` Date Issued._z-- 7 Application is hereby made to the.San Joaquin Local Health District for a permit to construtand.ins�ta`II the work herein described. ,:' This application is mad in c mpliance with Count Ordina ce 4 e istin les arid_Regullations: ''�=� �� r JOB ADDRES5%LOCATION--- - - - �iti4 _`�<'` CE TRACT ? Owner's Name A - ��__ f c c � - � r:# .. d- � � '_ on Address----�' _. �- P; . '�( ! ..�' �`.� '� A , s I .-.Ph e , _.City. - ---- --Zip Contractor's Name L._c . _ F + — -� •� �.•. R-�:�- --r i f License # --.-. .kr7_ Phone % �r Installation will,serve: Residence ' $ ' d ❑: Apartment House.❑ Comm rdal ❑ : Trailer Court ❑ Motel �] Other----C I�0...j"- P-.-,_1 C2: s o rr Nusmber of tivingunits:-.:__---._- Number o_f"-1"be.dLr,oto: .m,s.�`,� "•).GLa)rctbf ayge G rihdecr. _--- Lot Size---- / iI1 GQ! WdteSuPPIY Public System-and name . - --- � P i Character of soil.to a depth of 3 feet: Sand ❑ Silta } - ❑ Clay ❑ Peat❑ Sandy Loam ❑ �Clay Loam ❑ A 3 Hardpan❑ Adobe Fill Material__ I- If yes t )Plotshowin Ian, � � � { p g size of lot, location of system in relation to wells, buildings, etc.�musi be placed on reverse side.) fi NINSTALLATION: '.(No 'septic farik or"seepage pit permitted if pukilic sewer is EW available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK i - ------------------------- M -- - ------------ - ---------------Liquid Depth._ Ca pa o d: i YP -Material-.. . � No: Compartments.--.__` --- . . P y - -----------T e- , -_ bistance to nearest: Well. 4 { _ - PC— Prop.- inq _rs_.- j _-_ --Foundation- LEACHING LINE- 'f-'1 _:":_..Length of each lin_e._ � ; No. of Lines :. ----_ Total.�eng tho F 'D' Box. '-.Type Fitter Material, ��C�, C i YP Depth Filter MateriaL.� De � ; 'Distance,•to earest: Well _`h- Foundation V'L __ _' Diameterf` 3�i _- ... .Nx ; - LF : Line----- c ..- Property AGE PIT Depths " Number- --� -: Rock Filled Yes. No EP Water Table Depth *1- 3------ ------- ------ ----- -- -----Rock Size ) _ Distance'to nearest Well". .--C}�-- ---- o ation k 1 -_ _--- :-.Prop, Line. __' _ t- REPAIR/ADDITION Prev- Sanitation Permi`.t-# . - F = ► i ) ` un = ------ --.Date. -- --- 41 - Septic Tank (Specify Requirements)_.---;..._._'-"--, �. i ' = = = = - Disposal. Field (Specify Requirements) ' --- --------- -----. ` ------------ ---- - } --------------------- - t (Draw existing and 'required addition on reverse side) '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 Regulations of'the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: J "I certify that in the performcince •of'the work for which'this permit is issued, .I shall not employ any person in such manner as to become, subject to Workman,s Compensation laws of California.','. .. i Sigiined-=----'------------- = R k - - t k BY - i s T -------- - -------- itle._4� z � (If other-than�:owner) � • �.. «. , s USE ONLY ' APPLICATION ACCEPTED BY -= - ---------- ------ ------ -DATE -DIVISION :� ; DIVISION OF.LAND.NUMBER--------------- --•- - -- -- - ----_-_- -- -----:-:------° ---------------- ; -- --.DATE ADDITIONAL. COMMENTS...---_-----:------ ---------------- E --------------------•------------------------------------------------- ----- --------- . ------------- -------- --------------------------------------- ------------------ a ----------- ------------------------------- ------ .�„ � I {{------------- -------------------------------------Final Inspection by: -- --------------- - �» e ' �r -- - ---Dat ----- EH 13 24 r+�. 1 l .1 t I SAN JOAQUIN LOCA! HEALTH,1DISTR�ICT ,�; � �}" F&s 21677 REV.7/76 3M