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i "• FOR`OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------- �� s (Complete in Triplicate) Permit No_ . _3_ .__ ------------------------- --------------------- - - DIssued-_5 ate _. --------------------- ------ ------------------ f This Permit Expires I Year From Date Issued Application is hereby made t4o *, n Saln Joaquin Loc I e Ith District f a permit to construct and,install the work herein described. This ap aj'Qn m ce wi C u r c Nndexisting Rules and RegulationJOB ADDRESS/LOCATION_:-- C :- --=--- -- --------�v'Q��1' l�'QJ�OGc�- �� CENSUS TRACT Owner's Name 6 -------- P�.t�uC� --------------------------------------------------- city .. --- ----- Phone Address--- ---------- 1 � City zip - - r.. el Contractor's Name "- "". - = ---- --=-- -- License #-- +J o Phone_-a .". Installation will serve: Residence%. Apartment House-E] Commercial ❑ Trailer Court ❑ + . .... Motel ] Other ------- - -------- I-----.-.,- Number of-living un its:-- Number.of bedrooms. _ Garba'ge.Grinder_ Lot Size _ --- - Water Sup I Public S stem and name---- -----------------------------------------_ _ _ ___----------- ------------------ -------------------Private �r Character of soil to a}depth of 3 feet�� Sand ❑ 'Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [ ► # Hardpan ❑.N Adobe:❑ i Fill Material- If yes, type_.__--____`------' {.(Plot plpn, 1howing size of lot, location of system in relation to-wells, buildings,'etc.must be" laced on reverse side.) NEW INSTALLATION:" (No:septic lank;or seepage pit permitted if public sewer is available within 200 feet,) >e - PACKAGETiREATMENT [ ] SEPTIGTANK [ j 'Size." k__ t - L-------------------:-------- L,iquid Depth___ ------------ Capacity -------- --- TYPeTr�Ls`: �4Materia)--.:Foundat::-:"_:."No. dol partments v _ _ iDistance to nearest:.Well.--� --'(�� '--------- -- ----- ion---7 _-.f_ __ --.Prop. Line:- •-- # ... . W- LEACHING LINE [ .] No, o Lines.' - Length of each line.•;___ _ Total Length -__. ------------------- ---------- - ----------- g -- 'D' BqR �_- -_T)pe Filter Mate rial_ Y X� epth Filter M�terial � -- Dista�ce to nearest: WelIL€+ `d� --------" Foundation s"-. _.Property Llne ""-""-"-"-" 4. SEEPAGE PIT [ ] Depth'___- _`-,_---Diameter-----___s----"-""-Number-------------------------------- t --------- _-""-_-"-"""_ ______ Rock Filled Yes ❑ No'❑ Water)Fable!DeP,t ei' ;�" ------- - ---Rock Size ----- ------ Distance to'nearest: Well"-_- ' 1 } - --- --- Foundation ------" - - Prop. Line ---" f " REPAIR/AD�ITION (Prev�5anitatiorrl^a;Pern;rR _ 1..� - '"" Y Date--.-: - 1 ; -----------=---- --------------- Septic Tankl(Specify Requirem`nts}""��___-__,. _ __;...- '-------------- = = Disposal Field (Specify.ReauiTetriets} ------- --- --------------------------------•--------------------------------------- -------------------------------- --------------- - ------------- _. k ' l ------ ------- ----- --------- ------------------ ----- -------- --- --------------------------- --•--- _ ._- ----------------------- �- -------=--------------------- ------------------------------------------------ ---------------------------- 4 ------------------ exist ----------- . -- 1 existing and required addition on reverse side)' t I hereby ce�fify that I have prepared thA 'cation and ihat the work will -be done in--dccordance with San Joaquin County Ordinances,) State Laws, acid-Rules and IRegulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the folio ng: 17 I - ,,,,,,_. i "I certify that'in the pe orma"`� nce o#'the work FoF which—Mis permit is issued, I shall not i y any person in such manner as to become Ysubject to. orkrnan?s „Corrie nsation- laws of California." Signed------- �� 7� - 1O - --- :_ :--- _ � - caner .�-Title . {!f•otHer thcih owner) i . FOR'DEP.ARTMENT USE ONLY l APPLICATION AKkPTED. BY__�---`- ,i---- = --------------------DATE �-fa = DIVISIONOF LAND NUMBER- - ---1M__ - ------ -------' -------------- ---------- -------- DiATE----------------------------------------------- I ADDITIONAL COMMENTS. -M -------------------T. ------- ------------ ------------------- ---------------------- --------------------------------- ------- - --------------------------- --- --—---------- IM ------ ------ --------------------- ----------------- - ---- -------------------------------------------------" -----'- ;, -•�- - - - .- --r-C- ---- - _' _ .. Final Inspection"------- -------- 4 - ---- - p •on by:-----= ` - . -- ----- --------------------------------- _ Date--- z r- EH 13 24 II SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 Rev. 7/76 3M 1 _- - -- -- -- - _".090