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FOR OFFICE USE: FOR OFFICE usk: -------------•----- APPLICATION SANITATION PERMIT - -'-'--..... . .._.. ........• - Permit No....7..... -S`� �' " (Complete in Triplicate) . - Date Issued.... ......••....... •-"-"" ....................... This Permit Expires I 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,•5d9 nd'existing Rules and Regulations: JOB ADDRESS/LOCATION....-.!"' --- ----------------------------CENSUS TRACT................................ Owner's Name .... .:._ ...... ---------- .................Phone.--------•- Address..... Mi-'- city__----- ------------------_-------..----Zip---------------------- - -- -- Contrac#or's Name ... _. .. . ............ .License #--z �� . f .Phone-- 5/?) Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Moel ❑ Other.......-- ----- --------------------------- - Number of living units:....... .....Number of bedrooms...... Garbage Grinder----.._.--.Lot Size........... ..___.- -. ----- -- Water Supply: Public System and name_...... ..---- --------- --------'---.....-' ' . .................... ...... -------- ------ - ----- .------------.Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam EJ Clay Loamx i 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,) f PACKAGE TREATMENT l t [ } SEPTIC TANK ( ] Size......x..f;_X_ 1 0-.:---••- -------- ----Liquid Depth. --------------------- Capacity- .....--... ' v� Capacity_. ..v�. Material . . No. Compartments...... �/t ,�-.Type-- - ,- '=' - Distance to nearest: Well---.------ _�. .......Foundation.......'. . !✓.:.. .. Prop. Line.....-.................. LEACHING L1NE [ ] No. of Lines __ __z-- ------Length of each line......... . ...Total Length ... ... .................... t 'D' Box..... .....iType Filter Material....... .. .....Depth Filter Material.. ... .. Distance to nearest: Well--------------------........Foundation-------------------------...Property Line.......... __"----- SEEPAGE PIT ( ] Depth-----........__Diameter-..---------....I....Number----------- Rock Filled Yes No ❑ Water Table Depth.--------------------- = - - -- --- ------------- ---Rock Size........ ------•-------- Distance to nearest: Well-------------'..................__-_ Foundation.....----...-.- ..Prop. Line---------------------...... REPAIR/ADDITION (Prev. Sanitation Permit#-''---'-----------------.-7- : ---- -.-----_Date-------------------------- ---- -----'-'-----.) Septic Tank (Specify Requirements)------= -- --------------------- - - = ......- -- - ---- Disposal Field (Specify Requirements).1 .........--- .. . t --------••------------------------------------------------ -` --------- ----------. - ----- • '--- ................--------- -------------------- ----- - ---------- (Drow 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 of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: 1 "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 subject to Workman's Compensation laws of California." Signed_--' `Owner. By-------- Title.............. - - - 777 --- ---- - (If other than owner] 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---.----- 1 3 DATE .....1 /-2/?.�__.....-_ -------- - ................ --------- - ' DIVISION OF LAND NUMBER.- .......... -------------- - - ---DATE---_.............. .......... ADDITIONAL COMMENTS. ............. ........ --------------------- ------ -- -- -- - ---- --------------------- i ------------------.---•------------------- _...... .'-- ..-'..'-- -- --. --- 1 Final Inspection b ... Date. r ........_.. . EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7176 3M