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FOR OFFICE USE: / FOR OFFICE USE: <br /> / APPLICATION FOR SANITATION PERMIT <br /> ---- (Complete in Triplicate) Permit No._,78'---7.a_-a-- <br /> ------ Date Issued..-f-:7-.7 <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.. CENSUS TRACT------.-..- <br /> ---- - ------ -- - --- - -•-•-- ...-----------------...-------- ...- <br /> Owner's Name. .. ... <br /> ---- Phone.----------- ------ -----. <br /> -- _ . - <br /> Address---- .... <br /> City_..... --------- -------- Zir ---------- ------ <br /> Contractor's Name-- .... . ........License #.'c�Q. �7J......._Phone.: ------- <br /> Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ <br /> I ❑ Other......... ---­-------­--------- <br /> Number <br /> --- ------- --- ---••Number of living units:-.__/ ---.--Number of bedroom age Grindar------------Lot Size-_.�..�-..�..! .��.- ............. .... .. <br /> Water Supply: Public System and name.. - ...---............................................................................... ---- ....---•--------.Private'❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat.❑ Sandy Loam a 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [ ] Size __�..x�}�_.�0-_------ Liquid Depth.-.. ..------------ ----- <br /> Capacity-I.P.190-- Type- -:----.-... .Motor ial..........:No. Compartments... ------------------ <br /> Distance to nearest: Well.:._... r ---- -- ----- - - -- -----Foundation 1_0... ..... ..Prop, Line-1.0.. -...- <br /> LEACHING LINE [ ] No, of Lines i.]-------------- ------Length of each line,.------J40-Q--.-.....-_Total Length ................. <br /> 'D' Box... ......Type Filter Material-.-./-: . . Depth Filter Material-j r------- -------------------- -------------------_ <br /> Distance to nearest: Well--------------..............Foundation------------------------....Property Line.-.-.----.--- -- <br /> SEEPAGE PIT ( ] Depth....A-r.Diameter-.13- --- .._.....Number......-'---------.............. Rock Filled Yes No <br /> Water Table Depth------------------------ -------- =------------ ---•-•--.Rock Size--.--- <br /> Distance to nearest: Well-------------------------------------------Foundation.- ..............Prop, Line ------------------ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.......-------------....-...-....... ..-............Date.......•:------------_--.---..---.----------) . <br /> Septic Tank (Specify Requirements)...:................. . ------ <br /> Disposal Field (Specify Requirements)....-----------------= • ........ .......................-..... ------------------ ....... ........ <br /> ---- ----------------------- ---------------------- ------- - - .................. _-_ ------------- <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 Mules 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 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed..-.-. --------- ------- --- --Owner <br /> BY------------- - -- ---- ....... Title .-. <br /> .-: .. e• ...... . ................................. - .--. _. <br /> (If other than owner) <br /> TODEPA MENT USE ONLY <br /> APPLICATION ACCEPTED BY- ------ - ----- -------------- ---- -- ....DATE7 ._.... <br /> DIVISION OF LAND NUMBER..'-.y.. 5 ! � DATE. <br /> � ---------- .----...-- ------. -----ADDETIONAL COMMENTS <br /> t <br /> ................................... --------..................... ----------------------------- ------------------- - --....-----•---- --....-......--.... <br /> ...... ------- <br /> �.-.. ---------------- ---•----•---•-------- - ------- <br /> FinalInspection by-.--, . ...--------------..---------.------- --.. -- ------- .........................................Date. ------- - ----------- ----- <br /> E14-13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fre77 REV. 7176 3M i <br />