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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------- (Complete in Triplicate) <br /> Permit <br /> ' --------------------------------= ------------- - - . <br /> dv "`a` Date Issued...�a <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: µ` <br /> JOB ADDRESS/LOCATION... ----------------------------- .--- -- ------------------------.CENSUS�TRACT------ -------- - --------- ---- <br /> Owner's Name - - Phonep'r�11� <br /> - ------------------------------------------- ------------- - /52-------------------- <br /> ---------------zip f� - Cit Zi <br /> !�.. r Y --------- P------------------------------ <br /> Contractor's Name__`�.p ___________________ License # 71 'j9__-_-_Phone.f �S'' _� .___. <br /> Installation will serve: Residence>( Apartment House ❑ Commercial ❑ Trailer Court ❑.� <br /> Motel ❑ Other --_ <br /> of living units:_____-------Number of bedrooms..__s g �� >� <br /> ----Garbe a Grinder.__ _mot Size------ +� � ------- -------- <br /> Number - - <br /> Water Supply: Public System and name----------- <br /> -------------------- <br /> ___._____<--- _.-.:__ �__ ��• �� _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 [ ] Size__________________________ ________________________________Liquid Depth--------------------------- <br /> Capacity i <br /> p Y�----- ----TYPe-----------------------Material----------=------------ --No. Compartments----------------------------------- <br /> Distance <br /> ------------------- ---------- ---Distance to nearest: Well -----------------------------Foundation--------------------------Prop. Line--------------------------- <br /> LEACHING LINE [ ] No. of Lines_____________________________Length of each line..-:_._,_.,__r__f_­----- __..__.Total Length.__._______________________---___-.--- <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 E]—,— <br /> Water <br /> � <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)--------------------------(--------------------I--------------------------- ------------ ,_ ---- ------ ------- <br /> Disposal Field (Specify Requirements)_-_ __ ___ ._ - - ._._ C/ <br /> ----- -------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- <br /> �-' -- �- ----- ----- ---------- ----------------- -- ----- ------------- -------------------------------------------------------------------------- <br /> {Draw ex sting 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 sublpqt to Workma 's Co ensation laws ctf California." <br /> Signed--------- ---- ,-- Owner <br /> Title r <br /> ----- -- -------------- --- - <br /> {If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- J ----'-- ------------------------------------------------------ ----------DATE---- f-' - 1a ---- --- --------- <br /> DIVISION OF LAND NUMBER. --- ---.,___ ---- ---- ----`-------------------------------------------------------DATE------------------ - <br /> ADDITIONAL COMMENTS------------------------------------------------------------------------------------------------------ ---- --------------------------------------------------- <br /> ------- ----- ----------------------------------------------------------------------------------------- --------- -------------- <br /> ---------------------------------------------- -- --- -- ------------------------- <br /> -------- ----- - <br /> FinaiInspection by --- - - ------------------------------------------------------------------------Date --------- - -------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />