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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No ------- -------- ------------- -------------------------- (Complete in Triplicate) -------------- p Date Issued -�Z- ruct and --------------------------------------- --- This Permit Expires 1 Year From Date Issued e work herein described. is hereby made is the made n Joaquin in compliance eLocal with CounDistrict Ordinance permit and existing Rulestalnd hRegulat ons, described. This application CENSUS TRACT ----------•---- JOB ADDRESS/LOCATION .-_f.�-✓�-- -�---------- -------- - - - ------------ Owner's Name ------!-' ----- ---- ---------------------------------------------------= ------ --------Phone ----- --------------••---------•---- --------------- -. ------ .--- �''�'i'---------- -------------- City - --- ----------------------------------------------------- Address -- -------- ------- - F Con#ractor's Name .: ,, � `- /` -------------------------------- License # ---------.-------------- Phone Installation will serve: Residence m Apartment House❑ Commercial : Trailer Court ❑ Motel ❑Other - --------------------------------------•--- Garbage Grinder - Lot Size - -------------� ----------------•------ Number of living units:------------ Number of bedrooms ------------ Water Supply, Public System and name ---------------------------------•----------------------------------- -- ----------------------Privateap El Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ Peat(_1Sandy Loam .0 Clay Loam 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.) NEW INSTALLATION: (No septic.tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------ ----------------------------------- Liquid Depth ---------------------.----- _-- No. Compartments ------•--------------- W Capacity -------------------- Type -------------------- Material---- ------------ p Uj ------Foundation ---------------------- Prop. Line ------------ -----•-- Distance to nearest: Well ------------------------ 09 Total Len th ----------------•----------- LEACHING LINE I ] No. of Lines ----------- ------------ Length of each line---------------------.- g i 'D' Box ------------ Type Filter Material -------------------- p _ Depth Filter Material --- ---------------------------•----------- Distance to nearest: Well ------------------------ Foundation ----------------- Property Line. --------------- ----•--- De Depth --- Diameter ---------------• Number -------------------- Rock Filled Yes ❑ No �❑ SEEPAGE PIT [ ] p ---- Water Table Depth ----------------------------- --- -------------.-Rock Size -------------------------------- Dist ------------------------ ---•- Pro Line ---------------------- Date -------------------- to nearest: We --_-------------------------••----- -- .Foundation ------ p• -----' I REPAIR/ADDITION(Prev. Sanitation Permit -------- ---------------------------------------- Date -- ------------------------------- Septic Tank (Specify Requirements) -------- -------------:------------------- ---- Disposal Field (Specify Requirements) --- ' - � ----------- t ----------------- vi ----- ----- (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 i County Ordinances, State Laws, and Rules and Regulations of the. San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in such manner as to beco esu lett to Workman's Compensation laws of California." Signed ------------------------- Owner --------------------------------------------------- Title (If oche than owner) FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY ------- ------ -------- - ------------------------------ -- --------- --- --- - BUILDING PERMIT ISSUED ------------------- ---- --------- ------ ------------------------------------------ ADDITIONAL COMMENTS ------------------------------- ----------------------------------------------------------- ----------------------------------------- ------ -- `--- -}-------------------- ---------------------------------------------------- - -------------------- Date, ' ' --- - --------- - Final Inspection by. :__ �_ �� ---------------------------------- --------- - JOAQUIN LOCAL HEALTH DISTRICT r H 9 1-'b8 Rev. 5M J