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FOR OFFICE USE: FOR OFFICE USE: <br />' APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.-.�- --� 5 <br /> ----------------------- <br /> ' r <br /> 4 <br /> -��--••••----•�-�••-�•�_�••���• ---- ----•-------��---... This,Permit Expires 1 Year From Date Issued 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 Ordinanc o49 an existing ules and Regulations: <br /> JOB ADDRESS/LOCAT ON._ ;.-:..-.__. + .- S� _ <br /> CENSUS TRACT <br /> l... <br /> Owner's NahA4.a -_� <br /> Address... Phone--------- <br /> ---- . .:,--- <br /> --- i P . - city . ......--- zip <br /> Contractor's Name........ .............. _ / �} <br /> . <br /> License #-34-21. 1. .. .Phone-.y(L <br /> Ins#allation will serve; Residence ❑ Apartment House ❑ Commerciaio Trailer Court ❑ <br /> Motel ❑ Other....--.....- <br /> Number of living units;...-.............Number of bedrooms....... _Garbage Gfinder-_...........Lot Sizeje:0_440 -.._ <br /> ............... .... ........ <br /> Water Supply: Public System and name------------------- -- •-----.Private F­1Character of soil to'a depth of 3 feet: Sand ❑ Silt F] Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe9 Fill Material... <br /> . -. - - 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 [ ] r Size-------- ----- ---..- Liquid Depth.-•-:----....- Vy <br /> Caacit �..� <br /> p y------ --------------Type--- ....---=-.-Material •-- ..--_--:-._No. Compartments.................................... <br /> Distance to nearest: Well------------------------ .......Foundation-------..... .... . . --.Prop. Line........................ <br /> - <br /> LEACHING LINE [ ] No, of Lines.- <br /> -------------------- of each line---------•... ...............Total Length -- ........................... ....---- <br /> 'D' Box.......-....Type Filter Material------ -----------Depth Filter Material..--------_------. - <br /> Distance to nearest: Well---------------- Foundation.---...-_------------------Property Line...............I.....-. <br /> SEEPAGE PIT [ ] Depth_-_`"-_-- -----Diameter--------------------Number---------..........------------- Rock Filled Yes ❑ No❑ <br /> Water Table Depth------------------------------ -----•- .--..Rock Size....._..... <br /> ........................ <br /> Distance to nearest: Well---------------------------_-.--..._-•----Foundation-------------------.-.---.Prop. Line....-............. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#,--.--_------- ...___..Date-----------------_- <br /> Septic Tank (Specify Requirements).-- j <br /> R ..._-• . <br /> .--- , <br /> ---- <br /> Disposal field (Specify Requi4ements). . .-. ---------- .. <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 <br /> ollowing:"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 <br /> to become subject to W an' CasatioA laws of California." <br /> Signed------ <br /> ----- - -- - ------ -- - <br /> - .- ...-----• ---�----- -- --- ---Owner <br /> By.. _Title <br /> s ......... <br /> (If other than owner) <br /> f0_R EPART ENT US ONLY <br /> APPLICATION ACCEPTED BY lLc. .... . -- - c ------------ -----DATE <br /> DIVISION OF LAND NUMBER. - - -------- ------- -- ----------------------------- -- ........DATE........ ..F-....--------- -- .. ...... <br /> ADDITIONAL COMMENTS <br /> --------------------------- k <br /> , 7` ... .'....--��3 ---- - - .......... ..... .. - - -- <br /> ------ ----•-•---------------------- ------- - ---------------------------,.::..-----=--------.:_.------------ <br /> Final,lnsp6ttion by------------------------- ...... --------------------------------•----•------------•--- ---- - . ---......._Date. C`� -7�-...---.................... <br /> Eli 13 24 SAN JOAQUIN LOCAL HEAL DISTRICT FSS 21677 REV. 7176 3M <br />