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­6 <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------- }..... % <br /> "i (Complete.in.Triplicate) Permit No... <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 fora permit to construct and install the work herein described, . <br /> This application is made in compliance with C ty Ordinanc No. 549 and exist) Rules and Regulations: <br /> ; <br /> JOB ADDRESS/LOCATION.-- / ------------- <br /> - - CENSUS TRACT <br /> Owner's Name.. - - = Phone�� a� 1 <br /> Address-is-I�-- ---- = - City a'f---------------Zip-�- 6 --- <br /> �-^ <br /> ` Con rector's Name_` --- ----- -- ----------- --------- �./� 5 3� Phone.-� � _`_.2 <br /> License <br /> lnstallation will serve: Residence ❑ Apartment House❑ Commercial .Trailer Court ❑ ` <br /> Motel ❑ Other-------------- ------------------------------ <br /> Number of living units::- ------Number of.bedrooms-------------Garbage Grinder------------Lot Size_-- ----------------------------------------------------- <br /> Water <br /> _________________________________.__.-.--.---Water Supply_ Public System and•name----------------------------------------------- ------------=-------- -- --------=--------------------------------------- ------Private <br /> r Character of soil to a depth of 3 feet: Sand ❑ Silt❑ - Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam ❑ <br /> k � <br /> `Hardpan❑"`:Adobe � Fill Material-..---------If yes, type------------------------------- <br /> (Plot <br /> ----------------- -----------(Plot plan, showing size,of lot,'location of system in relation to wells, buildings, etc.:must be placed on reverse side.) s <br /> NEW INSTALLATION: '(No septic tank or seepage 'pit permitted if'public sewer is available within 200 feet,} oe ' + <br /> r i <br /> PACKAGE TREATMENT [ ]' SEPTIC TANK' (� /�5ize�-¢---_Z/X�s 9------------I--------------------Liquid Depth --y------------- <br /> ------ <br /> -------------:--- <br /> F. `. I- a. _..Type�1 - -Material__ _____No. Compartments-------------------------------- <br /> Capacity--{ .per r ted <br /> r Distance.to nearest: Well__- dQ________-.__---_--_--------Foundat.ion-- 14-- ----- ,_Prop. Line------..-- _.-- <br /> LEACHING LINE g 1-- ------------ <br /> 'D' Box____---___T a Filter Material-s'1f"�_. _ __De Depth Filter Material-_! <br /> Length.--.---_-�U___----- <br /> ( No, of Lines------------------ ----- Length of each line._ ._ <br /> YI? �A P atenal = l ------------------------------------------------ <br /> I <br /> ----------------------------- ---------- <br /> ` 'Distance to nearest:`Well-_/&O- -. ___Foundation --- � :- ----.Property Line... ----------------------------- <br /> SEEPAGE <br /> ---1/ J- -:---. <br /> ' � . :..-. . ... . ._,;.. ..;. � ----- t Rack Filled ' <br /> SEEPAGE PIT j ] Depth_-.-:----._''____Diameter_____________--------Number___-------:-------______._ Yes ❑ No ❑ <br /> 1 Water Table Depth - " i------------------------------------------ -- Rock ;Size------------------------------------------------- <br /> Distance to nearest: Wella:---------------------------------- ------Foundation.-'------:----------- --- Prop. Line------------------------- <br /> _-. <br /> I a <br /> REPAIR/ADDITION (Preva Sanitation Permit#------------t------_-----------------_------_-------Date_--_ :_'::-- -_-.-----_------+ - } <br /> Septic Tank (Specify Req(jirements}---- ---- ---=--- t - := ---------------- -= ------ ------------------------ ------------+------------"`:--------------- <br /> Disposal Field (Specify Requirements}- - ` ^:,r <br /> ----- ---------------.---_-------------`-----.--------.-------_------;--------_----.--------------------- ----- _ <br /> . - !, - ---__.- - --_.__ __ ________________ ---- ~ ..-#--------------------- -- <br /> --------------------------------------------- , ATL. -ti <br /> --- -- ----- -- <br /> y (Draw existing and required addition on reverse side) t <br /> I hereby certify that I 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 fallowing: <br /> "I certify that in 'the performance of the work for which this permit is issued, I shall not employ,any person in such-iffianner+as <br /> to beco s b' t t 1 Wor en's Compensation laws of California." . <br /> E .. <br /> Signed ------- --- ----------------------- ---Owner <br /> 711 <br /> BY = � ------Title- .< - -=---------------- --------- --- --------- ----- <br /> (if other than owner)" t i <br /> FOR DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY =-------------'-'---- -==------- ---- ------------- ----DATE _ _ - /------ --- <br /> F DIVISION OF LAND NUMBER:----- -------------- ---------------------- -------- ----=-- -------- ---- ---------- --------- --DATE-�------- ----- -------:- F------- --- <br /> ADDITIONAL COMMENTS------- ---------------------------------------- --------------- -- ------------------------------------------- <br /> ----------------------------------------------------------------------------- -- -----;---- ------ ----:--------------------------------.----------- ------ ------ ..------------ --- <br /> ---------------------------------=------ ------- - ------------------- ------------------- ------------------------------------------------------------ -------------=------= <br /> ------------ <br /> - ---------------------------------------------------------------- --------------------- <br /> ----------------_--------- <br /> Final Inspectlort by. = 'A - - - Date <br /> ---------------------------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21,577 REV, 7176 3M <br />