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{„ FOR- OFFICE USE: ` FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------•------------------------ --------- - ----- ]7- - (Complete in,Triplicate) / Permit o___ __________ ________ --------------------------------------------------------- - ._� -" Date Issued_-_7-�-�"_�� " _________________________________...__._____..._._-_. This Permit Expires 1 Year From Date Issued . 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: s - --- --CENSUS TRACT - -- JOB ADDRESS/LOC�4Y -- ------- `-'' "� Owner's Name---c-�-- � --- - --- Phone---- ----------------- ---Address l -_2-- '------ --�- ------- City---- -------ziP . Contractor's Name--------- - -- ---- -_---r./ Appt6rtment ~ -----/�""r�'--- ----�- - --License - -��'-��---Phone-------------------------------- Installation ----- --- -Installation will serve: Residence House.❑ Commercial ❑ Trailer Court ❑ - Motel Q Other_-_: V Number of living units:_.:_-_::_._.__Number of bedroom.s--._ __--Garbage Grinder--_-- Lo# Size----- __-___.__ _—.____.________________. t - Water Supply:I Public System and name - - - PrivateEl Y Character of soil to a depth of 3 feet: Sand ❑ Silt'❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ ' Hardpan E] Adobe ❑ Fi'lt''Material—---------If yes, type_______________________________ (Plot plan, showing size of lot, location of system in tela#ion towells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: ''(No septic tank or seepage pit permitted ifpublic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] r SEPTIC TANK '[`1 Size---------------------------------------------------------------Liquid Depth---------- ---------- -- -- Capacity--- --------- Type--------------- ---- --Material----------- -----------No. Compartments-- - - ---------- ------- ----; F =. . .'Distance to nearest:..Well-------f..-, .----- ------Foundation--------------------------Prop. Line---------- --- i y LEACHING LINE_. [ ]_, -- No. of Lines- -- --- ----- -Length of each line----=--- ----------------------.Total' Length.--------------------------------------- `D' Box-------- -Type Filter Material-------------------Depth Filter Material--------------__--.------------------ - ------- ------ D i sta n ce -----Distance to nearest: Well_________________________---Foundation--- ------------------------Property Line____________--_-_.______.__.____ SEEPAGE PIT [J] Depth__._'------------Diameter.---------------------Number--___'?__-__.____----_-_-_____ ? Rock Filled -Yes ❑ No. Water„-Table Depth----------- ------------------------------- - --_----'--------------------=--------- v----[- ---Rock Size:------`- ---`--------------------------------- Distance tom earest:Well____=____= _.-- �'_� *'____. __.___.Foundation--------------------------Prop. Line--------- --_-__ REPAIR/ADDITION-(Prev:,-Sanitation Permit#-- ----------------------------- --'---Date------_-------------------------------.-------1 Septic Tank (Specify'Requirements)--. = = = :1= ----------------------------- Disposal Field Requirements) equirements) _- __ __ ___ ------------------------------------ _______________------------ ___ _ ------- -----__ .- -------------- � --- ----- -- --------- --- ----------- ---- -- --------------- ------------------------ -- 4 {DraJ6' isting 6ind required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done -in accordance with San Joaquin County Ordinances, State Laws, and Rules and', Regulations of the 'San_ Joaquin Local Health District, Home owner or licensed 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 become subject to Workma ompensation laws of California." Signed---------------------- ------ ----------------- -- --- - Owner P . I BY { - - -----:::;------------ : �' Title ---- j F !f o than owner FOR-,DEPARTMENT--USE-ONLY -- q APPLICATION ACCEPTED BY:;: '' - �Y ? Y ---------- - --------------- -`-- DATE -- ---- - ----•-----_---- - - --`---=----------- `' DIVISION OF LAND NUMBER.----' L ----.. _r 1 - ----`- - --------------DATE-------------------=---------- :------------- - - ADDITIONALCOMMENTS--------------------------------------------------------------------------------------------------------------------------------------------------------------:------------- 4 y ; -----------=-- --------- -------------------=-------------------------- ------------------------------------ s _ ------------- ------- ----------- --------- Final Inspection by: = — _ Date. ------------- ------- -------- ---- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 am r