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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .. ... .. f Pa....ermit N . ---'-: <br /> (Complete in Triplicate) 70 <br /> r <br /> ------------------------ ...... --...-- --- <br /> ........................... ................. This Permit Expires 1 Year From Date Issued Date Issuedlw,7-?✓ <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 /> 6- � lr R ���� �i�. CENSUS TRACT.. -----.......� <br /> JOB ADDRESS/LOCATION. - -- ---- - -------------- - -------- --­­------------------------------ -- - <br /> Owner's` ...._._ . - ------- ----------- -------------- -- ---------...: ---------.Phone... yo')) <br /> , y4' iot-L '5_14 <br /> Address-, . _ .. � CitY----- - <br /> tie <br /> 1� <br /> Contractor's Name........ - ...... .....---License #---'�y� �g.......Phone... ..-......---.r. -...- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------ -------- ---------_------- <br /> Number of living units:..___.-.......Number of bedrooms. .......Garbage Grir cdi r....--------Lot Size.--:�..��y..... « �.._- ��' <br /> Water Supply: Public System and name_. - ------ --------------------- _ - ----- ----,-.---'--Private <br /> f , <br /> Character of soil to a depth of 3 feet: Sand [R� Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam n <br /> Hardpan ❑ Adobe ❑ Fill Material - If yes,type---:�-------------------------- <br /> i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) j <br /> NEW INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ���` -.-.5- -. ~ '-------- <br /> ] ] Size - � ------ - -- -. Liquid Depth.------ - ----------------- { <br /> Capacity-_P.L-P....-----Type. P1ku'kq_ . Mate-rial--- C�i+tP-�_----..No. Compartments--- ....2 <br /> Distance to nearest: Well-------�v� - .....Foundation..... ._.`........Prop. Line-----3.�.-. _ <br /> LEACHING LINE ---.- ��- - •-, <br /> [ ] No. of Lines .-.._._.. <br /> -------------Length of each line,....--- ..... ... Total Length ....�--��.-.-.---.--...----..-.--- i <br /> 'D' Box.... ......Type Filter Material.... f?r..."1-..Depth Filter Material:;<.-..• ��..........•, __:_.................................... <br /> Distance•to nearest: Well-------- .........Foundation------------------------ --Property Linge--5.----_-.- ........ <br /> SEEPAGE PIT [ ] Depth............._..Diameter....:...............Number_._-._------------.._...------- Rock Filled, Yes E] No E] � <br /> _ .�. <br /> Water Table Depth------------------•-------- --- --:Rock Size----- ........ <br /> Distance to nearest; Well------------------------- ........ Foundation ..................Prop. ,Line.�_........................ <br /> . <br /> REPAIR/ADDITION (Prev. Sanitation Perrnit#--------------------------------- ------........-Date-----------..---------.-.-.--.----_--- <br /> Septic Tank (Specify Requirements)... .................... --- f ... .' ,.tr , <br /> ....--.-- <br /> Disposal Field (Specify Requirements)- ..................: ...•-.--__--. _ ---- -----. --.------_---....--.------- <br /> --------------------- ------------------ <br /> -----------•---------------- ----=------- <br /> ]Draw existing and required addition on reverse side) i <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 subject to <br /> v+n..)..W.__orkman's Compe ation laws of California." <br /> Signed--- - -- ------------------------------------Owner <br /> By- <br /> ................... Title........... ............ . .....---.. ................ --- --- <br /> sl <br /> (If other than <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- -- ---- - - - - -------------- ---- -----.---._,.----------------------- <br /> .-------- -DATE <br /> DIVISION OF LAND NUMBER......................... .. -- ----------- --------.....DATE...................... ...................._ i <br /> ADDITIONAL COMMENTS... ... ----- ....... .... ... .......... <br /> i <br /> . ........................... <br /> Final Inspection b �G'�,�`•-•---•-------------�-��------ ------- -----•-•- - --------------�- Date_ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fa 2}p EV. 7/76 3M <br />