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FOR OFFICE USE: FOR OFFICE: USL: <br /> APPLICATION FOR SANITATION PERMIT qq <br /> '<(Complete in Triplicate) Permit <br /> Date Issued_,.5..-.,,g <br /> -•---•................................_.....-_.. "This Permit Expires I Yeac From Date Issued �\ <br /> Application is hereby made to the San Joaquin Local., District for a permit to construct and,install the,work`herein described. <br /> This application is made in compliance ith ounty dinance No. 5Q9 and yxisting Ruies and Regulations: <br /> l , <br /> JOB ADDRESS/LOCATION. _ .. .. CE S TRACT.... - <br /> s ---------- <br /> Owner's Name.... i✓ 7 Phone - •... tJ <br /> { <br /> Address. CitY-----------------..._...----_... <br /> ----......Zip <br /> ---------.---------.--- - <br /> Contractor's Name...a } (� License # (/ X- -Phone_ . ( <br /> Installation will serve; ` Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ 120 <br /> I Mote! ❑ Other............................... ... .......... <br /> Number of living units:................NumBer of bedroom's':."""":Garbage Grinder............Lot Size------- +- _ <br /> Water Supply: Public System and-name--- --- =A ---- - --------------------• ----------------- ..... ........ -------- ----Private <br /> Character of soil to a depth of 3'f et: , Sand ❑ `Silt❑ Clay ❑ Peat ❑ Sandy.Loarty Clay Loam E]�L <br /> Hardpan ❑ #Adobe ❑ Fill Material.. ._. ....If yes, type______________________ <br /> y F <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,j <br /> PACKAGE TREATMENT [ ] SEPTIC TANK { j Size.. __/P P Liquid Depth.-_:._-_ ._ <br /> Capacity..r� _Type.-, ,� __ _ Materiai_...__�._._._No. Compartments.-.-___ <br /> 14-------------- -- <br /> Distance`to nearest; Well_.... . Foundation..._.` 0_.. ........Prop. Line........._. ---------> <br /> LEACHING LINE [ ] No. of Lines a i` ---------------Length of-each li- `.1'.:_: 1__0---------_..._ Total Length ...... ----- <br /> ---- <br /> 'D' Box.....�.=r. - <br /> Type F.ilter.Material..... .. Depih-Filter Material._.� -- <br /> ------------ ----------------------------------- <br /> . -kyr � <br /> DistancE;to nearest: Well---------------..:....Y..� aundat`ion.`--'.... <br /> ______ ----Property Line._.-_.._.---------_---._......� <br /> SEEPAGE PIT <br /> { j Depth-- -..-- -.. .Diameter-----------........-Number------. - -' ____- Rock Filled Yes ❑: No ❑� <br /> Water Table Depth-------------__-------_-------- ----------- ---------:Rock Size..... ..............._..........--- <br /> Pro <br /> Distance to nearest: Well-------------------------------------------Foundation-.-----�`-.......---. - p. <br /> Line ...--- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------- -- Date------...........-"- - --] <br /> Septic Tank (Specify Requirements) -....: ............ <br /> Disposal Field (Specify Requirements)------------------ - .--.---...--------•---...---- ---... . <br /> ---------------••-•-- .................. .....------. . ---.....------•--•--. --.. . -- ................ <br /> ------------ .............................. --------- ................ -----------­-------- -------------------- ------------ ............. ------------- <br /> (Draw <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 /> k to become subject to Workman's Compensation laws of California." <br /> Signed----- __-. ------ -... ........ -- ........ ...... . . ................ _. .Owner <br /> .......Title ......... ..... --------------- <br /> If of er a owner) <br /> FOR DEPARTMENT US NLY <br /> APPLICATION ACCEPTED BY-----------------_-- . DATE <br /> DIVISION OF LAND NUMBER..-..----•---. -- !� DATE------------------- - <br /> ADDITIONALCOMMENTS--------.........---------------------------------------------------------- ----- ----------------------------------- ---- ....... <br /> --..._...-__- --------------- - -------- --•--- --............_.......-----•------------.... ---- --- ............................................. ---- ---------------- ------ .......... ....... <br /> ---- - - - ------------------------------------------- - ------------------------------------- ------------ - ------------- - -- -- - -....--- ------ <br /> _._ <br /> �} n <br /> Final Inspection b ----------------------------- -----_---------- --- ----- - ---------- ---- Date. :=4- '.... <br /> EH 13 24 SAN JOAQUIN LOCAL MEAL ISTRICT F65 24577 REV. 7/76 3M <br /> i <br />