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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- .-. . <br /> Permit No....� :_-�. <br /> .............. ................. ......... ........... (Complete in Triplicate) <br /> 76K. ��_� <br /> Date Issued... ................ <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 AOrdinance No. 549 and existing Rules and Regulations: <br /> Le.' JOB ADDRESS/LOCATION........ � - - ....._._ U( ----:../7<4 1 � . . CENSUS TRACT............-------- <br /> .. ..... <br /> - -- - ---------- <br /> . <br /> �- <br /> ....�.. <br /> ... <br /> U7 �WOwner's Name..:....... ....: a d --' . <br /> .. <br /> Address.. - - --..-- --Cit------ .............._Zip <br /> / CContractor's Name.--.---- .... . e ---- ....... -- --- ----------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> tote] ❑ Other ........ ------------------------- <br /> Number of living units:....." --.--.._Number of bedrooms..-'t _...Garbage Grinder----- .....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 Loom Af 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 [ j SEPTIC TANK [ Size 1 -----------Liquid Depth------------ <br /> - - <br /> Capacity./.....0;...... . . xi-----Type_ ate-ria -'-------No. Compartments _..............................N i <br /> Distance to nearest: Well...... ....O - - - Foundation----_.l U . -.- -- .- Prop. Line...r_..... . .............0 <br /> LEACHING LINENo. of Lines .. -- e.__...........Length of each lin _-, .. <br /> g _�---#-----------Total Length .. z Q.�............ ...... <br /> n <br /> JX] <br /> �i <br /> 'D' Box-- 11�-.Type Filter Material./O._._ Depth"Filter Material--. ---------------------------- -------p <br /> y Distance,to nearest: Well...`--- Foundation...,"O-- ----------- Property Line....` -------------- 5n <br /> ..�.� 3----- V . <br /> IT j�'f Depth._.. 5Dicwae#er. .. . lqumber._...._. ____. Rock Filled Yes ] No ❑ <br /> Water Table Depth L7 3SJ. Rack Size... <br /> ..................................... <br /> Distance to nearest: Welld...................................Foundation....Jd-.---.--. ......Prop. Line.-- ............. . <br /> REPAIR/ADDITION (Prev, Sanitation Permit#_.-------- -------------------- ....--------_Date__---------- ) <br /> Septic Tank (Specify Requirements).... - ------------ --•- - --.-•-.-•----_----------.--.- -. -- <br /> . ... ......:......... -------- ------ <br /> Disposal Field (specify Requirements►'- .. ___ <br /> -------------- -------- ------ j <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 shall not employ any person in such manner as <br /> tobecome sto Workman's Corn n tionI' s of California." <br /> I �! IanPt� a� <br /> Sig ned.---.._ ....._.._.. .�.--.-W. ------ Owner <br /> By....... -------------------- -- - --------------- . ---------.......-- -_.... Title.-- ............. ------ <br /> (If other than owner) <br /> FORD ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY____ 3 <br /> ....DATE I..r-------- - ->.... ­­- <br /> DIVISION OF LAND NUMBER............... DATE....----------___ -.__------._ <br /> ADDITIONAL COMMENTS .......... .... ---.. .- <br /> . ........................................ -------- --------- ...... .......... ---- ------------ ...---- -- .... ........ ...... <br /> ------------- ..................... ............ --------- .......................... ...---- -------....--- -•-- - ------------------------........ -- --------------------- <br /> -----------•------•-- --- --- - ---- ..... <br /> rG <br /> Final Inspection by:.- . - -- --------------------------------- ------ ------------------- <br /> EH <br /> -----------------EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />