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1 11 <br /> FOR OFFICE USE: I ° FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT rF <br /> (Complete in Triplicate) Permit <br /> Date Issued���.a � ` <br /> ....... .- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin L cal Health District for a permit to construct and install the work herein described. <br /> This appl}cati is made in compliwith �C o. 549 and existing Rules and Reg / sm� <br /> JOB ADDRESS/LOCATION.. ..L�� � C� ......... t .CENSUS TRACT... <br /> Owner's Name ... _ .-.. . . -r--. .__.. = -..... . ................. Phone <br /> . <br /> Address...-... <br /> City.. Zip <br /> r <br /> Contractor's Name___ ��� --. _ <br /> �.. ..License <br /> Installation will serve: Residence [ — Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other. <br /> Number of living units:_ .. `s� _�-..-.....Number of bedrooms..-.�. Garbage Grinder...--__.....Lot Size...-...L o-- ------------ <br /> Water Supply: Public System and name-- .. ......---Private ❑ <br /> Character of soil to a depth of 3 feet; Sand ❑ Silt ❑ Clay ❑ Peat Sandy Loam Clay Loam <br /> Hardpan ❑ Adobe �r/ 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 [ ] SEPTIJ Size Liquid Depth..-----.----- <br /> ) <br /> Capacity.MOOTYPe Material.... <br /> -�C.�� 'v+:-vC�r.L¢No. Compartments - -...--- --..... i <br /> Distance to nearest: Well__ ..Foundation....... _ . . Prop. Line <br /> LEACHING LINE ( ] No. of Lines _ 2­----------- Length of each line.....--.cR,57 Total Length .. �_._ ................. . Y <br /> 'D' Box _3. Type Filter Material._ Depth Filter Material.- ..-.. <br /> Distance to nearest: Well------------ ... .......... Foundation......----------------------Property Line ................... <br /> SEEPAGE PIT Depth.-Z,5" _ <br /> �:_ ...Dit _._9_ '1 _ uer.......... ---.------...... Rock Filled Yes ❑ No <br /> Water Table Depth--------/� ------. .. ...-----Rock Size.......�+� <br /> Distance to nearest: Well.-- /0-0 _ .. ........... Foundation.... ti ....Prop, Line-, <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------- -- _ ....-.-_.Date.._.._.-.........- <br /> Septic Tank (Specify Requirements).. <br /> Disposal Field l5pecify Requirements)___.....- <br /> Y <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 Coun <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agent <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 Workman's Compensation laws of California." <br /> Signed.. '•... - . ..... --------Owner <br /> ,off ' <br /> BY ! �` ------- ---- ---- ... Title ------ ----------- <br /> (If other than6 a?ned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY........ .. ..... ... DATE .-�- -- -�. . . -°�- <br /> DIVISION OF LAND NUMBER ............ DATE . . .. ............... <br /> --- ----- --- ------------ ----- ...-- .. ....._ <br /> - .... <br /> ADDITIONAL COMMENTS.. _. ......... <br /> -- ---------- - ------- ....... 'A- --- ---------- -----tll��--------------- <br /> - -- -- -- <br /> Final Inspection by: Date---- <br /> -- .-- . <br /> EH )3 ?a SAN JOAQUIN LOCAL HEALTH DiSTRiCT Fos 21677 REV. 7/7�,3M <br />