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' FOR OFFICE USE: FOR OFFICE USE: 1 <br /> APPLICATION FOR SANITATION PERMIT ' <br /> .................................... .. <br /> (Complete in Triplicate) Permit No.......^ . .--- <br /> ---------------------------­-------- --- ----- <br /> Date lssuecI3:- X14 -- <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 /> Owner's Name..- !- --------------- --Phone. <br /> City ......_.. Zip <br /> .��............ ... .... <br /> Address_--- Y <br /> Contractor's Name:......,.. ..-__ _. Jo.3 ,.._._.,-Phone.1/.- <br /> Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Mote! ❑. Other......... . - --- --- ------- •------ <br /> Number of living units;......../_-Number of bedrooms..:37_.Garbage Grinder------------Lot Size._ <br /> Rr <br /> Water Supply;`Public System and name----- ---------------- -------------------------------- --------------- ••---- Private <br /> Character of soil to a depth of.3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ 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 > ' S�icze _ .X-`�------=---- Liquid Depth._.��.�_../a.............� <br /> Capacity.I'Ro_C�-------TypePAR .... Material ---- ------..No. Compartments-----.__:. ------- --------- --Q <br /> Distance to nearest: Well---_----, ----------- - - -------Foundation_.__c24P .......... - Prop. Line_ .-_ ..------- <br /> LEACHING LINE No, of Lines /...........--------Length of each --.-........... ..Total Length ..... .....- ......... � <br /> 'D' Box.. ..Type Filter Material s•.4 c.-.Depth Filter Material...._./—*...•-..­--------.•------ --, <br /> Distance to nearest: Wel!_ ............... . Foundation..0.4------------------Property Line..S_._ �---...... <br /> SEEPAGE PIT Depth_;?.%7.1.....Diameter.._3-4--.---__.Number_..__.�_____________________ tr Rock Filled Yes,(] Na ❑!�� <br /> r <br /> Water Table Depth.------ --- ---------`- -- ---------Rock Size._ ..."....................••--..-•---�e; <br /> JDistance to nearest: Well-----1d.a_ -...--.-,----.. . ------Foundation_ 1�4 ....... .Prop Line--�..A-,-...4_. <br /> REPAIR/ADDITION (Prev, Sanitation Permit#.--- ------ -..- -----.Date-------------------------- _- ---=.- -----) <br /> ................ <br /> Septic Tank (Specify Requirements) ...--------------------------------------- _------------------ ..............-- -•--------------- ..... --- ---� ..... � <br /> Disposal Field (Specify Requirements)- --------------- <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 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 sub( t o Workman's ompensation laws of California." <br /> � <br /> Signed.__. - ._-:.. -. - .. _ ..---- -- --------------- __ <br /> __Owner <br /> G ! <br /> ..... Title. . <br /> (If other than owner) <br /> a <br /> FOR DEPARTMENT USE ONLY i <br /> t <br /> --------DA . '`� . ... ..... . ........... <br /> APPLICATION ACCEPTED BY_ ... _. _... ----------- ..-------_.... .............. <br /> DIVISION OF LAND NUMBER .........:..." ...... .....- DATE-- .---...---- --- <br /> ADDITIONAL COMMENTS_........... _ ---- --- _.. <br /> ------------------------------------'-------------------_ <br /> -------•-•---------------•- --------- ---- ----------- ---------------­------------ <br /> ,;-----.- --------------•-------•-- ------•-----Date. . ------- . . --. -. k --- ..... <br /> Fina( lnspectwn by .............. ----- --- <br /> -------- ------- ........ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/•76 3M <br />