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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- --------- - -- P------- ---------- --- - �-- - <br /> a <br /> (Complete in Triplicate) Permit No___________------------ <br /> ---- <br /> ___________ <br /> ---- -------- ------- ----- ---- -- � <br /> Date Issued------- <br /> _______________________________ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and,install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION--- 7=- - - CENSUS TRACT <br /> Owners Name'--- -----Phone--------------------------------------- <br /> Address- <br /> ----------------- ------------------- <br /> Address. --------------------- ---------------- ---- -------------- <br /> CitY 1 Zi 9 f �J <br /> Contractor's Name--------= ---- --- _ -------------------License #��+ L:- --Phone-'- �- 4---'--f.----- <br /> Installation will serve: ; Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> r r. <br /> Motel ❑ Other-=-------------- <br /> . ... ,.� . :: - - <br /> l Number of living units:_7---1-------Number of bedrooms -----Garbage Grinder------------Lot Size-------- ~..................: . '_-----_-.------- <br /> ;__- <br /> Water Supply: Public System"and name-------------------- ---- . -_.--' ----- -----------------------------.--- ---------------------------------Private ❑ . <br /> Character of soil to a depth of 3 feet: Sand [J Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ _ <br /> Hardpan ❑ Adobe ❑ Fill Material___-_ _---_-If yes, type----------_____________---.__ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,-etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (N6 septic tank or seepage 'pit permitted if public sewer is'available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size----------------------------------------------------------Liquid <br /> s Depth.--------------------- <br /> -Compartments <br /> ------------- <br /> :Com artments________________________________k$__-- <br /> 9- <br /> Capacity' _-TYpe--- ___.-_-- - - Material... -_ :_ --_No <br /> kDistance to nearest,Well----------------------- ---------- -------Foundation.-=-----'--------:-------.Prop. Line- =- ----------------------- <br /> O <br /> i <br /> LEACHING LINE J .] No. of Lines----------------- ----- Length of.each line.---_-------------------------Total. Length ----------------.------------------_ -- <br /> 'D' Box------------Type Filter Material--------------------Depth Filter Material---------=-------------------------------------------------- <br /> Distance <br /> -----:--.---____-- ---------------------- <br /> Distance to nearest: Well----------------------------Foundation---_----------------------_Property Line------------------------------------- <br /> SEEPAGE PIT p i ❑ <br /> [ ] � Depth. -Diameter-------------- Number---.------'------ --_--�-------- � Rock Filled �Yes No ❑ <br /> Water Table Depth. - = -= J Rock Size <br /> Distance to'nearest:Well----------------------------------------------:Foundation-----------------------------Prop. Line----------------------_' <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------------------- ---"--Date------------- ----------------------------------- <br /> Septic <br /> --- .- ---- -----Septic Tank:(Specify Requirements)----==---------- = == = -------------'---- ---------- --------------------- <br /> - - --=---------=------------ <br /> }---/�- <br /> Disposal Field (Specify Requirements)—w--- � " -- . _ ------_f'f__�_�-ry'• -'- -fv�----- -3" - <br /> ----------- -------- ------------------------- ------- --- ------------------------------------- <br /> ------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that.] have prepared this application-and that the work will-be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of_the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 steal! not employ dny'person in such manner as <br /> to become subject to Workman's..Compensation:,laws. of California.'-'. <br /> Signed_ --- ------ ----------------------- Owner <br /> ----- ' <br /> - .. _.Title � �------------=------=------------ <br /> (If other than owner) . <br /> t <br /> F )RDEPARTMENIT'USE ONLY <br /> APPLICATION ACCEPTED BY---------- = ----- ------------- - --------DATE al <br /> DIVISION OF LAND NUMBER-------------------------------------------------- ------------- l --DATE- --- = -- <br /> ADDITIONAL COMMENTS----------------------------------------------------- ------ ------------=-------------=---- --------------------------- --- ----------- - -----------#----------- <br /> --------------------------=-----=-----------------------------------------------------------------------------------_-- ---------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------- ------------------------------------------------------------ <br /> ----- ----- ----- ------------- ----- - -------------------- - ----- <br /> Final-inspection b _______________-___Date._____ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 Rev, 7176 inn <br />