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- FOR OFFICE USE: r FOR OFFICE USE: N PERMIT q /APPLICATION FOR SANITATlO i permit ----- (Comp Triplicate I R fete in Tri ica e Date ' Expires 1 Year From ............................. This Permit �ate Issued the i Application is hereby made to.the San Joaquin Local Health District andlrexlist ng Rulconstruct es and Regulations: work herein described. � This application is made incompliance,}with County �j��ff /,... CENSUS TRACT. ............... �`. .. . 1'!- �. .. � �-6...... JOB ADDRESS/LOCATION....... ;, .... .... one Ph ..- Owner's Name... - Zip---=-- -- ---�---- I.City .... r Address---- . ��..-.-�x�---- -1�,1�---= - _.....---- -- _ _.License # 03. --: - o e------ -•---------------- ------- Address.... ph n Contractor's Name.._ Installation will serve: Resiidence/9 Apartment House ❑ Coli mercial ❑ Trailer Court ❑ Motel Other.- ------ --------- ----- / � --.-..Garbage Ider---------•.-Lot Size----- G��'-G'- ...---•-=---• Number of living units:..._ - - -- ------------- - ----.-Private . Number of bedrooms..... Gar a e nal------------------- ❑ Y {I Water Supply: Public System and name------ Peat' Sandy Loam [] Clay Loam ❑ Character of soil to a depth of 3 feet: '�SandX Silt Clay 1-1 1 Hardpan ❑ Adobe ❑ Fill Material . ..-- --..If yrs, type......... -------- ----•— plan, showing size of lot, location;of system in relation to wells, buildings, etc. must be placed on reverse side.) (plot p [ p blit sewer is available within 200 feet,) NEW .INSTALLATION: (No septic tank or seepag p p Liquid Depth.--- e it Size..tted if ur ---•---- -- . PACKAGE TREATMENT [ ] SEPTIC TANK ( ] -T e. .. ..... ..... .. .. Material) -- ---.--.-- -_-.:No, Compartments.... Capacity- �-- ��_......-- - Type - - 1 . Foundation------- -- - --- - -- - Prop. Line------_-- e to n No� ofLines wrest; Well-- •- ..Length of each line).,..-- Total Length .. ..-----:• 9 [ LEACHING LINE [ 1 I-.Type �pth Filter Material-..---- ------ ----- 'D' Box.---.... .:.T a Filter Material------...--- •-- .Del �I tion.... ....Property Line.---•--- • -- -- --- - Distance to nearest: Well------------ ---- Rock Filled Yes ❑ No .Diameter.."---------- --- Number-"-- --"...Fours Depth.--.-. - - � .. SEEPAGE PIT [ ] t ' i-•... ....Rock Size......... .. . . .. •---- Distance to n�arest: Well------------ ----- -� -- ----- --- --�I .....Pro Line-- ---- ----- -- -� - -. Water Table 'Dept ---------•--•-----•- -- - ----- ----- II._-Foundation ----- ..... . p. ID te.- ._. : . --. :__. --- -..... REPAIR/ADDITION (Prev. Sanitation Permit#-- �� i 1To, Y Septic Tank (Specify Requirements)-.-" � C Requirements) .-- . - ---fid-- - ��'`� � •-- ..... Disposal Field (Specify -- �- i ------------•------- --------- ----- ----------- 1 i - «� (Draw existing-and on reverse side) 1lication and that the wori4 will be done in accordance with San Joaquin County r I hereby certify that I have prepared this app i Ordinances, State Laws, and Rules and Regulations the Son Joaquin Loe�ai Healih District. Home owner or license agents signature certifies the following: to any person in such manner as "I certify that in the performance of the work for which this permit iso issued, I shall not emp y ( to become iect to W rkm n's Compensation-laws ofa1i{ornia:" �" ' - ----------- -------Ov Iner Il I Signed- ---- ---------- -- - -- �I e = �t, (If other than o n r) - FOR DEPARTMENT, ,SE ONLYit .-..-...--- -DATE I APPLICATION ACCEPTED SY----------- - ---------- ----- ------- DIVISION OF LAND NUMBER,--- .. ............ ,_ - . ---- ----- ---- . _.- i =..... ADDITIONAL COMMENTS-------------------- - ' - -------- --------- t ......,. --- ..--_-----'----- ----- --..: ._- ------------------------------------- w ..._. .... ...... -- ...... --"----------- --------- --- .. .....--- ---- -'... . - --..Date.....------ - FSS 21677 REV. 7/76 3 Final lnspecilon by------------------- - I ' EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT -