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FOR OFFICE USt: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Q Permit No---------------"- -- .-.-•---------------- ......... . .. .. ..........--- (Complete in Triplicate) Date Issued-"S� x. . This Permit Expires 1 Year From Date Issued .......... .................. ...... ................... to Application is hereby made to.the San Joaquin Local HealthDisNot5for a 49 an'drmit ng construct and d instalgul l the work herein described. This application is made in complia with County Ordin '`�` 4__ .__.CENSUS TRACT.ance ..--- -----,.. JOB ADDRESS/LOCATION......_. " _ one --- - . .- .. .- Owner's Name_.. /. .,-.... S-�-d S �.... ....--City-- / "- Zip -- ---• ! x.r Address------ one ' - -- ..-:.. ---License #-�.�-- :.�-� - Ph .: f4"�� Contractor's Name.-.__-..... - -•-""-- �- �" Installation will serve: Residence F-1ApartmentHouse ❑ Commercial ❑ Trailer Court ❑ 1 Motel ❑ Other...... ---- -"- ----------- Number of living units:- -."-----Number of bedrooms.._.•-.-Garbage Grinder:---- --:.:Lot Size--.-.✓-- k -----------------•--•--Pry ate [ , Water Supply: Public System an name'".: .- ---= Peat ❑ Sandy Loam ❑ Clay Loam _ k Character of soil to a depth of 3 feet: Sand ❑ Silt E] Clay ❑ . Hardpan ❑ Adobe Fill Material.- "--.If yes, type--------------------• " .... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 00 I NEW INSTALLATION: {No septic to or seepage pit permitted if public sewer is available within 200 feet,} Size .. .. Liquid Depth.-.- . --- PACK -- l PACKAGI: TREATMENT [ } SEPTIC TANK [ } .-._-. ---•--•------------------- --- - - - capacity__......-........Type=----_ ----- ...... material--------------------------No. Compartments--------:--------------------- ---- --Foundation..- .. ..... ...Prop. Line---- } Distance to nearest: Well-"-..--- I Length of each line------- .-_Total Length LEACHING LINE [ 1 No. of Lines ..{F{---.--..-""--""-"----. g D' Box f-TYpe.Filter Material.-._ .:�" a pepth Fi1t_er Material - --- ------— -- . - - I -----Property Line----•--------- -- ------ --- Distance P Y Distance to nearest: Well---.-�_--;�-- -- - Rock filled Yes ❑ No SEEPAGE PIT [ ]. Depth.-- ----.._!..-Diameter.--=---°--;-- -.::..Number. ------------- -------- . -- ' .Rock Size-- ....... --------- --------------•1----- ---- Water Table. Depth-..--"--------=-•:------ ----- f, _-.Prop. Line-------- ------------ Distance to nearest: Well---------------- ---- ----� -- ------.Foundation.. -- ..... - "- . `!.' Date------------- ------ -- REPAIR/ADDITION {Prev, Sanitation Permlt#"-.-------•---------- " . f Septic Tank (Specify Requirements). - - --- r--------- r�- p p Y q } --•--- ----- o2X- /.. pp �- f Disposal Field (Specify Requlrements)"_t.- .- -. r"" - -- -• ------ -.".. - ----- ---- . - r - k raw existing and required addifioon reverse side) I hereby certify that I have prepared this application and that tsan Joaquine work lbe daccordanceone in LocalHealth Dist ict. Hom owner orJlicensed agents k Ordinances, State Laws, and Rules; and Regulations of t he signature certifies the following: la any person in such manner as "I certify that in the performance of the work for which this.permit is issued, l shall not emp y to become subject to Workman's Compensation laws of California." . Owner k Signed---- "-". 3 Title.-- - ---------------- - f other than owner) F DE ARTMENT USE ONLY �-�- ---------------- -DATE - _- -- �3 .-7 APPLICATION ACCEPTED BY-------"----3 - DATE.------ - -- DIVISION OF LAND NUMBER.--. -- ADDITIONAL - -. .... ------- �d". -. .:�`."t----.-5. ate' �"�_----- -- - ADDITIONAL COMMENTS. ..... O"/-� . -... ...... ��- --- . . --- .............. ----- ..... ' --- -- ... f . - � ...Date_.. .. K Final lnsgectlon by:.. .".---.- ---"- --.- --- ...... ---- --- -- -------- ---- ... -- ----- F&S 21677 REV, 7/76 31 S N JOAQUIN LOCAL HEALTH DISTRICT EH 13 24