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FOR OFFICE USE- . ............................ .................. APPLICATION FOR SANITATION PERMIT F` .......... ...:.....:..: . :...........� - -.. . - _ Conrpleteln Tciplleate) . . . �...� .� Permit No. ...7r.:_.�3.a � s _ . This Permit Expires Doti Issued 9��LZ . p res 1 Year from Data Issued Application is hereby made to the San Joaquin Local Health District fora , described. This application is made in comp!( rice with County Ordinance permit to and existing Rules and Regulatiowork ns. � S�+c JOB ADDRESS/LOCA?#ON .-Q f_. �2-11 s!f i4Aa .....CENSUS TRACT Owners Name / Address ..--._:..._- i f`j. ��... . Phone _f�' _�-J�-3".3`.5 -- - .......-..-•-------- -••-•-•.........- Ci .. ° �`7-, .. Contractor's Name ....._ !°-jam ... - ...License - •---••......... --- Phone _ Installation will. serve; Residence Q Apartment House fl Commercia3 Trailer Court Motel ❑Other....._•-- ✓ --------------------- ------------ Number of living units------------- Number of bedrooms Garbage Grinder Water Su Public .... Lot Size -----•-------------------•-..... --.... Supply, c System and name .__....... . . . . ..........._....................._.----........... -----Private Q Character of soil to a depth of 3 feet: Sand[] Silt 0 Clay p Peat❑ Sandy Loam Clay Loam 0 i Hardpan 0 Adobe 0 Fill Material............ If yes, e (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc, 'must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if publlc sewer is available within 240 feet,! PACKAGE TREATMENT I, ) SEPTIC TANK` .. .. ..:..:.:................• Liquid Depth .. .:__...._..--- Capacity 04 '...... T ��d� e YPe ------- ---••--�aterial_.-----• ....:........ No. Compartments •�� - Distance.to nearest: Well lS�. r �.......................Foundation ....fes............ Pros LEACHING-LINE [ ) f Lines g . Line -SS.....:.......� Length of each fine.._... - ....-•--- ------------• .Q .. Tata! Length '©' Bax ..... _... Type filter Material .-----------Depth .Filter Material . /f..... Distance to nearest: Well ....�N f r . ..... ..... Property Line ._. Number .......-----• �.............• i Foundation L SEEPAGE PIT. [ ) Depth . Diameter •.................. --•-•---•----•-• Rock Filled Yea Q No Water Table Depth .-•------• ------------------------------- Rock Size Distance to nearest.• Well ._.........................Foundation Prop. Line REPAIR/ADDITION(Prov. Sanitation Permit# .....Z Dale Septic Tank (Specify Requirements Disposal.. Field.-(Specify: Requirements) .. • -- ..... ............... .......................... .............. --------- ------------ - --- M R .............,- ------------------- ` •mac uqN ay. (Draw existing and required additiorS`an.reverse side( I hereby certify that I have prepared this 4PIlcationand that the'work will be done .in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations,*IU the San Joaquin Local Health.District. Herne owner or iicen- sed agents signature certifies the following: � ` `' "I certify that Int performance of the work for which.this-permit-is Issued, I shall not employ any person in such manner as to become u , o Workma mpensation letweeof California." Signe Owner ----------•--• By :----- xitle .:......... (if other jho ow - = - - R-DEPARTME USE-ONLY . APPLICATION ACCEPTER BY T cam• - .... �--. -= = DATE.-.. r !.._:.---------- BUILDING PERM-If ISSUED .... _ - -- ----••-------•- ------- .................. ----..... DAT! ADDITIONAL COMMENTS ------------------------ - - -- - --------------------••------------------ -------- ---------------- -.--.--- -•-•-- .-._..-- n ion by ........ .......•----------••---------•-------------- -------------•----------------- -------- Fina( Ins action b .......-- -- •---...---• ...........................•---------- P Y ..............•----...--•----- ..................4.,------•---- - - -- �.-.-Date IEH 13 2 1--6)3 v' SAN JOAQUIN LOCAL HEARTH DIST 8/7h 3M r