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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------- Permit No. ... .___ P (Comple'te in Triplicate) � J=-----•----- ---------------- -167 10 , ........... This Permit Expires 1 Year From Date Issued Date Issued..-._s` Application is hereby made to-the San Joaquin Local Health District for a permit to construct and.install the work herein described. This application is made in compliance with County Ordinance No. 5 9 and existing Rules and Regulations: QQ L n. JOB ADDRESS/LOCATION. Q..-f� . .... .---- . ..._CENSUS TRACT.,_.............. Owner's Name.............. -- Phone--- ......................... Address-..------1~�._� City 1, .. ZiP Contractor's Name--- ----- -7e--- -- -- - - ------ -.....-_License # 4 _t _ .I. ..Phone.. Installation will serve: sidence ❑ Apartment House ❑ Commercial Trailer r Court ❑ Motel ❑ Other-.... . .... ..... ----- ------...... ---- Number of living units:......I--------Number of bedrooms_-_ ....Garbage Grinder.............Lot Size.-- -- .....r _ ._+ _.._. .. _. Water Supply: Public System and name - ....................... - ............. ---------------- ---•---•---------- -------------Private f� ;Character of soil to a depth of 3Tfeet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam 0 Clay Loam ( ' Hardpan ❑ Adobe ❑ Fill Material.. ....If yes, type.................... , s(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 00 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' PACKAGE.TREATMENT ( ] 'SEPTIC TANK -- ------------------Liquid Depth.-- ------------- _Capacity �_ ---Type.-•`:;,��dtt�.��..........Moterial------�(f_s� --------No. Compartments-_..�....................... Distance to nearest: Well.-.__ -- tie'-__- --- --- ---------Foundation.--_ Q .._... ._....Prop. Line-._.. .......... LEACHING LINE ( ] No. of Cines ._.... .._.___._:._':.length of each ling..----- . :....:....... Total Length ._..._..-----------_ 'D' Box: �.....T -e Filter Material r ----:-•------ •�� YP. r �. _ ,Depth Filter Material....-`� - - /,0------------ PIT -- - -- -- ` -•t Distance to nearest: We'll---�. `(...............Foundation_-_.(_Q0............Property Line... SEEPAGE [ ] Depth.... c!� .Diameter.___0-_�t._.... Number- ...-._ ________________ Rock Filled Yes J No Water Table Depth---------------------- ------------------ ---------------Rock Size.:..:./.. ....------. Distance to nearest: Well_-__1: Foundation._...____................Prop. Line.._-..-------------.------- . REPAIR/ADDITION (Prev. Sanitation Permit ------------------- . ....Date--------------__-_ -------- ) Septic Tank (Specify Requirements)_- ........./_ _ � ---------------- Disposal .....:......... ....... ... :..... _..... -----------------------------------.. Disposal Field (Specify Requirements) : . - .i�.��------------------------------------------ ---- ...._---•--------------------------- � --------......._----.._ d r - _ _..._..__..............¢..........._....--..-..........._........,..........._.........__..._.............--� } ------- ............. ................................................... - ........................ (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 bf. the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: s "I cern that in the i certify performance 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." Signed........................... Owner $y.. ............. Title........... ........ (If other than owner) { FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY...... .. ........... - t .-- --..._DATE .._.. -.. ` DIVISION OF LAND NUMBER. ----- - ........-----DATE---................... -------- ADDITIONAL - ---- ADDITIONAL COMMENTS..........- _- ` ....-. --........... .. ............... . -- - . --- •. . . . . -- Date. - ----- Final Inspection . --- EH 13 za" SAN JOAQUIN"LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M