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t FOR OFFICE USE: FOR-OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------- --- Permit No.__.��= <br /> (Complete in Triplicate) _----------------- <br /> ---------------------------- ------------ --------- ----- <br />.x <br /> --------.--- ------------------------------ -- This Permit Expires I Year From Date Issued Date Issued_.3�1� <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 �- --- ---------------- ---- ---------------- . Phone 'i <br /> _ �. . <br /> Address. -- - Z����-- -- -------Cit -. ..-... 'p - <br /> ' = " Y ---- Z <br /> Contractor's Name----- ---- ---------- <br /> - License #- �e`3�-�----Phone-------- ---- ----- <br /> Installation will serve: Residence [Apartment House.❑ Commercial E] Trailer Court ❑ I <br /> -r Motel E] Other------�`=------=------`-=---------------�--.. <br /> Num ber.of living units:__--. :--__._Number of. bedrooms----_?Garbage Grinder------------Lot Size---------------------- ------------- <br /> I <br /> Water Supply: Public System and.Warne. ; <br /> -------- -- ----------- _... _-_ ----------- --------------------------------------- Private �. <br /> Character of soil to a depth of 3 feet: Sand ❑ .Silt❑ Clay ❑ Peat❑ Sandy Loam R--� Clay Loam ❑ <br /> t <br /> ° Hardpan ❑ Adobe❑ Fill Materidl.-._-Y.--...If yes, type <br /> (Plot plan, show.i6g 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 [ ] - t Size-----------------------'----------:---------- --------_--Liquid Depth.--------.----------- ----- <br /> ] Ca acit Type: .-� ..---- - Material.:`------------- = No. Compartments---------------- ------ ---- <br /> n Distdnce to nearest: Well.-. -_,`----- Foundation:_-_---- _-, Prop. Line---------------------------- <br /> LEACHING <br /> ------------- ----- ---.LEACHING LINE ].] No, of Lines_ -.-.Length of each line..----. ---- - -Total.Length - - ,�._- <br /> D' Box---------:--Type Filter Ma�er.ial -------------------Depth Filter Material. -----------.-----------,------------------- ---- - <br /> Distance.:to nearest: Well--------- <br /> ----- -I---- -------=- n----------'--------=---'-k_``.P_operty Line-------_"-- -------------------- <br /> SEEPAGE PIT [ ] Depth-----------------Diameter -- Rock Fillet! . Yes ❑ N <br /> �.. �. <br /> Water Table Depth-------------- - ---- Size------- -------------------------------- <br /> r Distance to nearest: Well----------------------------- <br /> :------------'Foundation--___"-----r-- ------.Prop. Line---------------- ----- -. <br /> REPAIR/ADDITION [Preva Sanitation Permit#___ ----==-===-- - ------:D­ate.__ X2-7'"-_7�------------------ <br /> Septic Tank <br /> ________________Septic.Tank (Specify Requirements)----------------- --- - --- - -- <br /> --------------- ------------------------------------ ---------------- = _ <br /> Disposal Field (Specify Requirements)----- _ --- - -£ _- ----- .-: ---------- <br /> } <br /> .-- ---------------. - <br /> --------- --------------------- <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 .Rules..�.and_Regulationsof-.-the-Sari-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 /> I } = California." ; <br /> - ---- -- - - f <br /> Signed-L. --_---_: -., man's .Co ensatian:law of California." <br /> to become subject to Workman's 1 <br /> 9 T f� <br /> BY-'------ ---------------`--------- -- ----- ------------- ------ <br /> Title/0- -- -------------------- <br /> (If other 'thanFowner} x <br /> } <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ' - - ------- -- ------------- =-----,---DATE----- <br /> DIVISION OF LAND NUMBER.-- ---- - ----=------=------- ---- -------------------------------------------- DATE , <br /> ADDITIONALCOMMENTS-------------------- --- --- ------ ---- --------------- ------------------------=----------------------- ------------------------------- ---- <br /> -- --•=------= --------------------------------------- ------------------------------- ------ -------------------------------------------- ------------------------------------ <br /> --------------------- ----------------- --- ------------- - -- <br /> -------------- ------------------------------- ------------------------ -- -------•------------------- ------------------------ <br /> -------------------=-----•-- --- ---------------------- <br /> ------------------------------------- <br />'.. Final Inspection 13 - ------.Date ' <br /> p Y= - <br /> EH 13 2a SAN JOAQ LOCAL HEALTH DISTRICT Fas 21677 efv, ���b snn <br /> Iy _ - <br />