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_ FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....----..--•........ ............... __ _ <br /> (Complete in Triplicate) Permit No. -....`- -:----_-- <br /> --------------------•- ------. -------:.._ <br /> Date Issued-S:%.J:15_ <br /> •-----_-----••------ "- ...... This Permit Expires t 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_...:--- _0-<.. !-- ---- - --------.CENSUS TRACT.---------- -------.--.. <br /> Owner's Name. -.-..:. /c- ��- . "� .f -------------------- ------------------- ............ --- Phone -'9-6 <br /> Address---- .........-4�7 4------------ .......... ..- - City.. I� /L .�-..............Zip. .- ------ <br /> ..... -- <br /> ---. License #-c� �r .SF ._..Phone- --"' . <br /> Contractor's Name------- ... SLC J -_....._ <br /> Installation will .serve: _ Residence X.- Apartment House ❑. Commercial ❑ Trailer.Court❑ <br /> Motel Other------ ---- ___...... <br /> Number of living units:_.............Number of bedrooms.... Garbage Grinder-...--------Lot Size-------- .- -.---------.---.--- .......-- <br /> Water Supply: Public System and name---"-.-----. ................. ---------- -------Private 8--� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam lay 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ) Size...".--.---------------------------------------------------Liquid Depth.--- _--.---.-..._.- <br /> Capacity- ---- -------------Type--------------- -.....Material--------- ........ -----No. Compartments..---- ------....--------J <br /> Distance to nearest: Well-:---------:__..--------------------------Foundation------- -- Prop., Line----_-------_------ <br /> LEACHING <br /> ---_-----.- .--LEACHING LINE [ ] No, of Lines .--.. ......---. Length of each tins -----------------------------Total Length . <br /> 'D' Box_....... ..Type Filter'Material........ ...........Depth Filter Material............------------ ------------------- ........... <br /> Distance to nearest: Well................, -- - Foundation----------------------------Property Line-------------------.........-------- <br /> SEEPAGE PIT [ ] Depth................Diameter.*-_---_--.._.____Number-------------'k-------------- Rock Filled Yes ❑ No❑ <br /> Water Table Depth-------------- ----Rock Size.............._.-...... i <br /> Distance to nearest: Well.............------------------------------Foundation------------._............Prop, Line-------- -------...... <br /> .---- <br /> REPAIR/ADDITION (Prev. Sa_g,itation.Permit#----- ------------------------- - ---- --------_Date........:...---.---------_ ----.j <br /> z 1 <br /> Septic Tank (Specify Requirements)_.......... _._.__ ._ <br /> -------------- - _. rn-.... -----•- ------- <br /> Dis osal Field [Specify Requirements)______. -----------"-------- <br /> ----------------------------------- ­... . .. -------------------------------- .............. .................... ... <br /> (Draw existing and required addition on reverse side) <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 following: ' <br /> "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as <br /> to become subject to W <br /> man's Compensation laws of California. <br /> Signed-.--'- `_ ---------------------------Owner <br /> BY-------------------------------------------------- .........................-...Title - -------- ......... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED''BY:, ------------------ - ----------------------------- <br /> DATE 7--"- --- - ----- <br /> DIVISION OF LAND NUMBER..................... w - .....DATE.- ..... ....... - <br /> ADDITIONAL COMMENTS.. ........... .. <br /> ------- a. ------ - <br /> --------------------------------------------------- ----- ----------------- -------------------- •-:•--------- ------ -- -...-.... --- <br /> --------------------------------------- -- ------ .Y--- ___ ­ <br /> Final Inspeetlon b ---- - - .-Date.--------- .. ..-. <br /> y:----- _----- - - -- -. .-...--- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ^ F&S 21677 REV. 7/76 3M y <br />