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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT r <br /> ........ .............. ------ <br /> Permit N <br /> (Complete in Triplicate) "---' - /�"--....-. <br /> Date Issued- �(Q.. � <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 /> 00 <br /> JOB ADDRE <br /> 55/LOCATIO �]} �{fir ...4 .4-- --w.--... CENSUS TRACT...................... <br /> Owner's Name , /f/C= ............... .......Phone-------------- <br /> Address.. <br /> ------ -:- _- <br /> lxt4 <br /> �Address - :. . . I' . ..t -------- --------- -----------......-City d - Zip...:... <br /> Contractor's Name..._.. . .,, , -y7.- . -... Q. p--. <br /> -License #--. _ Phone..... .. <br /> Installation.will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-------------_ ......--.... ---------------- <br /> Number of living units:._.J----..-,Number.of bedrooms---... ..Garbage Grinder......-------Lot Size................................................... <br /> . .. <br /> Water Supply: Public System and name............. ... ....... -----------------.......................Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay X Peat ❑ Sandy Loam [] Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fit[ 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: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK [ I Size-------------- -------------------------------- ...........Liquid Depth-----........ .. ..------- <br /> No. - -------- - ------� <br /> Capacity.............. ......Type.......................Material....... ------- Compartments -------- <br /> Distance to nearest: Well........................................ . Foundation............- . .. . .....Prop. Line....... <br /> -- .._.........-..�` <br /> LEACHING LINE [ j No. of Lines....... .............. Length of each line . ----..-__-- ...... ...... Total Length...-.................--------........... I <br /> 'D' Box..:.........Type Filter Material......... ........ Depth Filter Material. .--. -- • -,- ---.--------------------.-.-----------------.--. <br /> Distance to nearest: Well----------------------------Foundation.......- Property Line.--------------------------------- <br /> SEEPAGE PIT { ) Depth_..............Diameter.:..................Number.----- ----._._-.._--------- Rock Filled Yes ❑ No❑J <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)..... i��fi._... .. � r�� -- f <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 Countyk <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed ag t <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, t shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed ._X �- Owner <br /> . .-- ate. <br /> B Title------------------------ ------•-- ------------ <br /> f other than own <br /> FOR WPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- -DATE . -- ---------- <br /> L." <br /> DIVISION OF LAND NUMBER..---------------- --- . DATE....... .......... ...... ------- <br /> ADDITIONAL COMMENTS- ----------- ------ --- ... ------•-----..... ---------------------. <br /> ....................... .................-•------- .--------------------:-----••--•--...------------­............... ----------- •- ------ <br /> .............................. ............... ---------- ........----------------------------_-:----------- .................. .................... - - ------------------------ ---------------------------... <br /> FinalInspection by =------------ .................................................. ..........--------------------•.......Date_-------•-----... ­------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7176 sM <br />