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FOR OFFICE USE: Or APPLICATION FOR SANITATION:PERMIT FOR OFFICE USE: >> P(Complete in Triplicate) Permit No..._ ---------------- This Permit Expires 1 Year From Date Issued Date Issued_ 1.:-l�'�� 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. 9 and existing Rules and Regulations: JOB ADDRESS/LOCATIO - ----- A V+ � --- ------------ ------- -- CENSUS TRACT--•------- = Owner's Name------------ '' --- --E ------ ------Phone----------- - Address � ----- ------------ - -- - --------- --- -- -- City. # Y zi Contractor's Name._ _ *P r' -- r ----- License_#_�� ----- '� -Phone lnstalfation will serve: Residence ❑ Apartment House ❑ Commercial Tr�rq C.-ourt--( ' Motel f ❑ Other------ --------- ----='�'"r"-- - �--- �� t Number of living units:------__ _------Number.of.bedrooms_.__ - Garbage Grinder________ Lot Size.... ----------------__--- -- Water Supply: Public System and name------------------ t --- Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay ❑ Peat ❑ Sandy Loam Cl ---------- Private ❑ ay Loam ❑ 1 r Hardpan. Adobe ❑ Fill Material_..__ --_-If yes, type-----,----- _ _____ t (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc: mu t.be placed on reverse side.) i NEW INSTALLATION:" .(No septic tank or see ' I P ge pit permitted if ul lic sewer is available within 200 feet,) PACKAGE TREATMENT [ J SEPTIC TANK r t h 4 ---�----'-_-- ---*�---'- -----Liquid Dept .--.T'--� -- P Y A. v 'TYPe Mater* = --_.No. Compartments_-.___ ' Distance to riearest: Well..'— ----------------------Foundation_: . Len th.of each line..-__-------._------- 'p. Total LengthProp. Line_.______,______ LEACHING LINE [ No. of Lines_.______: g -- Distance to nearest: Well-- feria! ------- p -_- .Depth Filter Material--------- 7 t �- ------------ ----- i f :Q' Box - TYe Filter Ma = Pro ----�� :»-- Foundation- / A SEEPAGE PIT .. p / __ arty Line-"- [!K Depth_ '� _.--Diameter .------- ----Number----------11 - ------- �4 /..� ill Ye --- �k Filled� ed s � No" • Water Table Depth---_------- ` --------------Rock Size:--- /,/, -- ---- --- ---------- ---- ' Distance to nearest:INeII.-- --._ - ® ---------------- '- ---Foundation-----_ --. .-.Prop. Line... J! - ff REPAIR/ADDITION (Prev, Sanitation --_.- '__-_- pate---_------------------- --- ) Septic Tank (Specify Requirements)....__.___.. ___________________ # : -------= :-_-:-- Disposal Field (Specify Requirements)___..________--_ i --- - --------- --------- - ------------=------------- - -------------------------- -- -- - ------------------ (Draw existing grid required- 1 Jrebycertif that ! have re orad this a txisting and that e a -- e - ----- - -------- -- --------- -- - g q red addition�on reverse sided Y prepared PP 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: r "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 Workman's Com sation laws .of California." . Signed------ -------- -- --------- ------------ ----- s-. .. -- -- . ---- Wnex --- = ------,------ B - - - ---- r ------Tite.----$Y-1 ----- - : -- , (If ofher than owner) FOR DEPARTMENT USE ONLY K, APPLICATION ACCEPTED DATE.---- --------- - - DIVISION OF LAND NUMBER------ ---------- ---- `- ------------------ :_. --------- 1T10NAL COMMENTS--------------------------- -- -- _ - .. --------------------------------= =-- ----- - - ----- --------------=- =----- -. --- _ -----------------=------ ' r. ----------"------ Final Inspection by:._--- - _.. _.. _ ,..r v - ------------------- EH t ------- - - - ------------ ---- ------ -_"---Dae - --- �� EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M