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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.. ._ e�'? i <br /> ------------------------------------------ -------If (Complete in Triplicate) <br /> --------- ------------------------ - I - Date Issued--- <br /> This <br /> ssued__-This Permit Expires 1 Year From Date Issued <br /> Application is hereby made toii <br /> �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. 349 and existing Rules and Regulations _ r <br /> o % = <br /> CENSUS TRACT _ ---------- <br /> ------ a <br /> JOB ADDRE55/LOCATI - - �-- ---- -- -- - �} ... ---- <br /> Owner's Name-'­,­- <br /> ----------- <br /> ame - <br /> --Phone---- - �---" <br /> ' F C� ----------- ------Zap------- <br /> Address------ --- - I/' <br /> W e - - �9= <br /> Contractor's Name__.. _ ._ __ License #_ z ' . - <br /> $ Phone � 747 6- <br /> 4 Ins}allation will serve: -' Residence Apartment House.❑ Commercial ❑ -Trailer Court ❑ <br /> 5 ? <br /> Motel ❑- -Other--- ------------ -------------=--.------ ----- <br /> Numbe'r of living units ., <br /> __ --_-Il--_-Number of bedrooms_'.___,--Garbage Grind -- <br /> er '.__---__Lot:-Size____- '---------------- <br /> { Water Supply: Public System a�nd'name--. -------- ---------.:---------------.---------------.-r--.------------..-- :------------------ _. ------ u: Private <br /> P .. <br /> Character of soil to a depth ofi�3 feet: ; Sand E] Silt❑ Cl ay E] Pea# ❑ Sandy Loam ElClay Loam <br /> � Hard <br /> pan ❑ 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, <br /> septic tank'or" seepage pif permitted 'if public sewer is available within 200 feet,) <br /> i I d Size------ ------------------`.--- �� Liquid Depth - f---h` <br /> f PACKAGE TREATMENT [ ] r.SEPTIC TAMC ['] <br /> I i y,=. ----- <br /> == `= =--- =Type- --------------------Material-----=-=-- ------ =` No. Compartments pi <br /> Capacit <br /> i <br /> bista�nce to nearest:.Well---------••--=-`-------------== Foundation.: -_ _Prop. Line-=------ ----- = � <br /> ll chi a Total. Length._:- -- ----- i <br /> LEACHING LINE' d [,]�:�•.of Lines --- ------ - -----Len-gth .of ea �1in - <br /> r> box --._'-.Type Filter Material _" :.Depth Filter Material_. _______._. ------------------------------- <br /> D' <br /> 3 ----------- - <br /> Distanca to nearest: Well _.__ _-,_ __.Foundation .Property Line. __ ---- <br /> ),. '. r ! a-. k Filled . Yes ❑ No ❑ <br /> SEEPAGE PIT o :[ ] Dep+__ --Diameter" Numbs <br /> - <br /> - ------------ <br /> Water Table Depfh.- _.-_---___I- __ Rock Size_ <br /> I F : <br /> Distdnce'to'near'esf:We11 -- _. - ------------------- oundation-- Prop. Line = <br /> - Date- =f---------------------- <br /> r <br /> -j- -------------I <br /> REPAIR/ADDITION (Prev. Sanitation-Permit#___------_________-__:°.---=-==----------------- <br /> ' ` <br /> - i p <br /> Septic Tank (Specify Requirements)- -- : ::-- ----------- ----=-------------- ----------------- ------------------------------------------- ---- ----------------------------------- <br /> I <br /> ------- -------------------------- <br /> Disposal Field (Specify Requ ements).-.-.- G - t� � _ t <br /> ---------. . -- -..- --_--- ------------._:, <br /> --- --- <br /> '- <br /> �, -- ----------- --------- -------------------------------- <br /> ---- ------------ <br /> ': <br /> 1 (Draw existing and required addifon on reverse side) i <br /> i <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 /> 6.1 certify that in the performance of"the work`for which this`perndt is issued,'I shall not employ any person in such manner i'as <br /> to become 'sub'ect to .Workman's Cam ensation jaws of."California." <br /> I � p <br /> - Owner <br /> Signed-- ---- ---- <br /> -�- ---�- I� -- ------ ---- .. <br /> -- -- -- -- <br /> If o <br /> ' �! - Title- � �``�--------- -- ---- --------------- <br /> By----------------------- <br /> � ':--- <br /> ther than owner) 4 <br /> I! -FOR'DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , <br /> I <br /> DATE. -Z3- <br /> DIVISION OF LAND NUMBER = DATE----------- ----- :------ -------- <br /> ADDITIONAL COMMENTS -"I------ --- -- ------- - - --- ---------- ---- ------- ------;- <br /> Il ----------------------------------------- ----------------- <br /> -- -------- - ---- <br /> FIN ----------- ------------------------------------------------------------ -------- <br /> - - <br /> ,---------------------------------------- <br /> - <br /> ..-. ._ - -- <br /> - <br /> - <br /> - Date -- -Z - <br /> Final.Inspection b If----- _ ----------------------- ----- <br /> EH 13 24 I� SAN JOAQUIN LOCAL HEALTH DISTRICT r&S 21677 REV. 7/76 3M <br />