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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �/Z AX Permit No- - -- ------- ----- - - ---------------- � ---- -------- --�---� (Complete in Triplicate) / -- - ------._--.- Date Issued -------- This Permit Expires 1 Year from Date issue ----------------------------- ork herein l the w Application is hereby }onismade:,.in compliance with made to the Joaquin Local CauntyDistrict Odinars a permit mo5490construct and exst ng Rules tand Regulations: described. This application ' :' ' `--CENSUS-TRACT -------- ----------------------------- JOS ADDRESS/LOCATION % � r .Phone Owner's Name T 5VJ y Address ------ _ =' City y Contractor's Name - 9'- License #_ 3__.- Phone .. ; --- - - installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ;❑ ti. .. Motel ❑Other ------=----- --------- ----- ------------ . ,,// Lot Size ------------------ ��'�----- f4 Number of living units:- >----- Number of bedrooms -----Garbage Grinder _- Water Supply: Public System and name --------------------------------- - -- ---------Private i Character of soil to a depth of 3 feet: Sand'❑ Silt j] Clay F-1 Peat ❑ Sandy Loam Clay Loam Hardpan ❑ 1,Adobe.0 Fill Material --------- -- if yes,type ------------------------ ells, i aY buildings, etc. must be placed on reverse side.) ` (Plot plan, showing size of lot, location of system in relation to w NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 204 feet,) t"`' Size------------------------ --------- Liquid Depth _M PACKAGE TREATMENT . ( I SEPTIC TANK f ] , tt --------------- --- Material ------- No. Compartments -------------------- - Capacity - ------------------ Type Foundation - Prop:Line ---------- ------------ ---------------- Distance to nearest: We ------------------------------------ I'E°,: th -----------•----------- - Length of each line--------------------- - --- Total Leng LEACHING LINE No. of Lines ------- -------- ----- � Depth Filter Material ---------`--`-------=---------•--------•---- 'D' Box ..-_-- --- Type Filter Material -------------------- 4F . t Property Line. Distance to nearest: Well --------------_--_---- Foundation --__--__.--__------__-- p tY I Number .------ ----- Rock Filled Yes ❑ No O - Diameter ------� -- ------- - SE;EPAGE PIT [ l Depth - -I-------------- i WaterTable Depth ------------------------------------------------ I -------------------------------------------- Rock Size l -Foundation -------------------- Prop. Line,-------------------•-- Distance to nearest: Well --------------------- I j • -------------------------------------------- Date ------- -------- -------"---------) REPAIR/ADDITION(Prev. Sanitation Permit E Septic Tank (Specify Requirements) _------------------------------------------------------------------------------- ''' .!` Disposal Field (Specify Requirements) - ''i''''-'-- - r -4 -- "--- ------ -------- ------------- -"__---_.--__.- ---- "-__-- D -----' _ ----------- - (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 Regulations of the San Joaquin Local Health District. dome owner or licen- County Ordinances, State Laws, and Rules and sed agents signature certifies the following: uch manner "I certify that in the performance of the work for which s permit is issued, I shall not employ any person in s thi as to become subject to Workman's Compensation laws of California." Owner --- By Signed -------- ---- - ------- --------- - _ --- �..f� 4Title -- ; . ti (lf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ---_- - BY ". DATE ..- _� - -'_ -1-------------- ---- - DAT -�----- -�------------- ------ --- ----- ( BUILDING PERMIT ISSUED ------------------ --------------------------------------------------------- -------- --------------------------------------------- - ------ - ADDITIONAL COMMENTS --------------------------------------------------------------- 1 ---- --- ------------------- ---------------- ---------- --------------------------- ---------------------------k - .r - ----------------- - --- ------- r• �, Final Inspection by: -------------------------------------------- SAN --- - - - ---------------- ------- --------- -SAN JOAQUIN LOCAL HEALTH DISTRICT :r E. H, 9 1268 Rev. 5M.