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FOR OFFICE USE: v FOR OFFICE USE: <br /> c APPLICATION FOR SANITATION PERMIT <br /> _-------•------------ -- ------- --- ---- <br /> ....... ..._.. <br /> tI (Complete in Triplicate) Permit Na.7 ."'P-.-"'-q <br /> f Date Issued.,:;" <br /> ---------------------- I!_..... This Permit Expires l Year From Dente Issued <br /> T <br /> r Application is hereby made to.lthe San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in cor4iplionce,with County.,Ordinonce No. 549 and existing.Rules.and Regulations: <br /> Z - -------- -------CENSUS TRACT:.::------ <br /> ------------ <br /> _.. F <br /> JOB ADDRESS/LOCATION. : . ... - --- <br /> Owner's Name ..v !- �1 -------- Phone,.. <br /> F •Address..---- - t._ 'E(fz.... - .. ...... . . ........ ...... ---- -- -Zip <br /> k Contractor's Name `I` ---�---z!�v..d :.............License #. 5 � .�....Phone_ ---------------_------------- <br /> Installation <br /> ;-- ��-7._.... <br /> Installation will 'serve; Residence:X Apartment House ❑ f Commercial ❑ Trailer Court ❑ <br /> f : Motel ❑ Other------------ --------------_------------ <br /> m' <br /> -------------_----------- <br /> Number of living units:__.__.i_._-...Number of bedrooms_...1__. .Garbage Grinder.-=..:-----:Lot 5ize... �-X...�.ZJ.. ----=-''_-'""" <br /> � Water Supply: Public�System ari�d name- ------------- - ---- -----------------. --------.-------�--- -�._._.._.._. ... <br /> . ...... --Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardp�n ❑ Adobe Fill Material - ..- -...If yes, type_..------------------------ <br /> [Plof plan, showing size of lot,jocation 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 [ ] Sf PTIC TANK [ ] Size ---------- ----- ----------=------ ------ .....Liquid Depth-----------------.......... <br /> Capacity ' �TYPe------------- -- ----- Material :----..-..-_----------:No. Compartments.-------:•............ ............ <br /> Distance to nearest: Wet]..........._........ ...... .._ ...� _.Foundation._..--.... . .... .... -'Prop. Line_........................ 1� <br /> LEACHING LINE [ ] No, of,`Lines ...-----------•............1ength of each line_---------------------------------- Total Length _. ----------------------------------�" <br /> I <br /> .....T a Filter Material. .:.. ...... .....Depth Filter,Material. _...---_-----...-----..---.:.-------:- ---------.----- <br /> i ,D. Ba�� -- - ...Type p <br /> Distanc&,to nearest: Well---------------- ---- Foundation-- ----=-`-=-•----'•--,._Property Line ............... <br /> -. _ � .., . <br /> SEEPAGE PIT [ ] Depth��._-. ...Diameter---------------.----Number-------------------------------- Rock Filled Yes ❑ No❑ <br /> Waterl�Table Depth................ <br /> _ Rock Size:...-.-_-- -,. . <br /> 1 <br /> i Distance to nearest: Well----------------- --------------Foundation.------ Prop. Line. - <br /> III <br /> REPAIR/ADDITION (Prey. Sanitation Permit#.............................. ........Dote................--- ----------------------------- <br /> - <br /> ) <br /> Septic-Tank [Specify Requirem J�nts) - .......................... <br /> ,...� -__..:f--.,•� - <br /> ----- <br /> Disposal Field (Specify Require`m` ents)................ ........ -.....7 Et - ---- ---.'""----- "rL-- <br /> �I' , <br /> ------------- -------------- ------- ` -- ----- ------ . ...... -.- ----- -------- <br /> I� -- <br /> I <br /> ---------= --------------------- --- -------------------------------- ------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prt�pared 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.performalnce of the work for which this permit is issued, I shall not employ any person in such manner as <br /> I to become subject to WorkmlIlan's Compensation laws of California." <br /> Signed--------- - ---------- -- --Owner <br /> ... ........... Title.----..-. ------�-r------ ........... ----------- <br /> (if <br /> ------- --(if other than owner) <br /> II <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.u�_� .... <br /> DATE <br /> DIVISION OF LAND NUMBER ��------------ ---- - DATE --------- ------ --- <br /> ADDITIONAL COMMENTS..----�- - .. ........ . <br /> -------------------------------------------- ------------- ------------------_._._.... <br /> ....---_-----•-.-•..............................'.yII'--___'_--._____-......_-......__-•--•--•-............--------------.---_-.___----__.._.__-._._.... ._.. <br /> Y1. ----------------------------- <br /> ------------------------ ..... ... ..... <br /> ............... . ........i'..- _......_........-._.__.._:.. ..--___._._.._....- - ... <br /> Final-Inspection by:_-.- ��e�"`- .�G - <br /> --•---------- <br /> EH 19 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7175 au <br />