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FOR OFFICE USE: FOR OFFICE: USE: II APPLICATION FOR SANITATION PERMIT • (Complete in Triplicate) Permit No...'.j.�i.:":5�f1 ..................... ......-............................ Date _•,_•,.__.__...•......... 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. 549 and existing Rules and Regulations; .... CENSUS TRAC•T....... JOB ADpRESS/LOCATIO `±�'"'........................... . Owner's Name... _.. � :.. a /.. - Ph n _�jfl�r �e�?. Address....... .............. .... ......:......... city.. ��..� f�t....•. .._. .... ....zip. ...... ...........License #. G„�.��f...:. Contractor's Name........... Phone..... Installation will serve: Residence g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [j other .............. ee.�i....._Garba a Grinder --:.........Lot Size.. --- t-• ........::..................... Number of living units:,__-.�,...:.-Number of bedrooms -.d' g : Water Supply: Public System and name .............. ............ .......... ....... .-................. :........ ....... .. Private' Character of soil to a depth of 3 -feet `Sand 0_ �'Silt C] -Clay ❑ Peat [ISandy Loam ❑ Clay loam (] Hardpan ❑ Adobe V Fill Material ............ If yes, type.... ............................ lPlot plan, showing sizes 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 [ l SEPTIC TANK [ 1 I Size ...................................: ...................... liquid Depth..:; .................... ....... • ,Capacity .. ...... ............... Type ................ ....... material ......................... .No. Compartments .................... ...... ..'r! .. Distance to nearest: Well.* ........................_....-....... Foundation ................ ........Prop, Line .................... -....------•---..,._...._. LEACHING LINE I 1 No. of Lines........................... ...Length of each line:_L......................... Total Length .............. ..Depth Filter Material ...............•--.... 'D' Box ............ Type Filter Material .................. - .-•---............ . ..-_. Distance, to nearest: Well ...........................,Foundation---•------- Property Line......--- ...._....._....... SEEPAGE PIT [ ] Depth...,. .......:...Diameter..........._.._ --__.Number...-----...__---.--._ - Rock Filled Yes ❑ No ❑ Water Table Depth.._.._...--•-• ............. ........... ...... ........ Rock Size----- .........._..:......... : ...........• -•-•Foundation ........... .. .............Prop. Ling ......................... Distance to nearest., Well ............. _.. REPAIR/ADDITION (Prev. Sanitation Permit #..-.-.••-.......................... ................ ..pate....... ...................... ................. Septic Tank (Specify Requirements).._-_..._....:,............................................ Disposal Flyd (Specify Requirements). •...-...._••----------- 4 `f V ...... -) ....... ....... ..................r.. .... --._-••_-•--_.r............._..-......._..... _....•.._•....._•__-__•__•_• (Draw existing and required addition on reverse si d e 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, 1 shall not employ any person in such manner as to become subje W rkm 's Co ensation laws of California." y Owner Slgned............... ... •._...Title-•-�_O ............................ (if other than owner) APPLICATION ACCEPTED BY.-...... .... :__.dn�': .-.--•...............DIVISION OF LAND NUMBER....-------•-••---•....._... ......................... DATE.- ;............:.............................. .... ADDITIONAL COMMENTS...................................................................... .... ........... .. .-•-.. -.... .. ...---- _ ---._.._..---.............._....---•..__--................. _ .. �.. _ ...... - 1 ---•---:---• .............. -..... .Date......_.................% ............ - !~ ., Final Inspection b :... _.............. y FQS 21677 REV. 7/76 3M EH '13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT �_ _