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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. .. <br /> ............. -------------------­ ----............... Date Issued.- ..' <br /> ..................... ................ ...--..-.... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District fora permit to construct and install the work herein described. <br /> This application is made in compliance with County Or.'nance Np. 549 and existing Rules and Regulations: y <br /> (... <br /> JOB ADDRESS/LOCATION..-.--.-� -.-1-- . --------------CENSUS TRACT-------------------------------- <br /> Owner's Name..,. . . . Phone...............-..................... <br /> Address.-----• �°c --------- ------ - City........ .. .............. ... ......__Zip------ ................ "t <br /> Contractor's Name....';.. .... . p r1 j 9s (��f <br /> - .. -. �.. '�j�'�' _ _ . ..License # -d /_6 Phone. l!{ T 1.-_._. <br /> Installation will serve; Residence ❑otef-1 <br /> Apart ent House E] Commercial E] Trailer Court El <br /> Ml <br /> Number of living units:..-../...--.-_Number'of bedrooms.._.Garbage Grinder------------_. ------------------- <br /> Lot Size..................._....... <br /> .............. --._._. .- <br /> Water Supply: Public System and name.. ....... :....._...-. Private �] <br /> /' <br /> Character of soil to a depth of 3 feet: t. Sand ❑ Silt ❑ Clay ❑ Peat ❑ ` Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.. ..-_ ---If yes, type_.-,__-------------_.._...__-- ' <br /> {Plot plan, showing size of lot, locution of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: ti (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--......'-------------Type-----•--- Material.--------------------------No. Compartments_.... ---• ................... <br /> Distance to - ----------------Foundation Prop. Line----------.---.----------_. <br /> LEACHING LINE [ ] No. of Lines---------------------------- Length of each line-------------------------.---- Total Length . ----.---------------------------- <br /> D I <br /> - ------------- <br /> D' Box..... ... ..Type Filter Material _..Depth"Filter Material------------------------------------------------.-----.-------. <br /> Distance to nearest: Well-----------------------------Foundation----------------..............Property Line_----------.-------- <br /> 1 <br /> SEEPAGE PIT [ ] i Depth....-_ .... ___Diameter....................Number_.-------I---------------------- Rock Filled Yes ❑ No ❑ <br /> r . <br /> Water Table Depth---------------------------------- ----------------------Rock Size...-- --- <br /> Distance to nearest: Well..........------------------------- - ------Foundation-.--------------- <br /> .........Prop. Line..--:.. --.-.-------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----.---------- - -----.Date--:-•,;•: --------- -----------} <br /> Septic Tank (Specify Requirements)...... -- --- . ---- - .......... ------------- <br /> Disposal Field (Specify Requirements)..... ...--- <br /> . . f-- ----- - ------ - --- - --------- - ------- <br /> - - -- - <br /> r_. .r-- rM <br /> (Draw existing'anci requATcladdition'on reverse sid-e-)­ <br /> I _. <br /> i <br /> 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 /> i <br /> to become subject to Workman's Compensation laws of California." <br /> Signed-----... -- - ----- -- --- -----------------•--- ....... _ ......Owner <br /> W <br /> BY ..._ Title ._.--..... <br /> (if other than owner) <br /> F Df ARTME T LJ E ONLY <br /> APPLICATION ACCEPTED BY............. . .� __... .. _ �.�.. . <br /> --------------------------- -DATE ........ ...y 7...�-.-- <br /> DIVISION OF LAND NUMBER ../, ---------... DATE------ ..... .. ....... <br /> ADDITIONAL COMMENTS....-• C� sriu.� /Z-[�` - - „^^ ^.- GC ..... .....-.... <br /> ..--- ------ " � ... -- ---------- ...----- <br /> .. --------------- ----- ----------------------------------------- - --- <br /> Final Inspection b .bate ___.. - .. <br /> y:....--- ----- -���--.... - G ... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT &S 21677 REV. 7176 3M <br />