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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> {Complete in Triplicate) Permit No. <br /> This Permit Expires 1 Year From Date Issued Date Issued_.... <br /> Application is hereby made to the Son 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 /> JOB ADDRESS/LOCATION..... . . } . ( �.. °f rt ' <br /> - --- _ CENSUS TRACT-- - <br /> Owner's Name ._.. Phone'l� _ <br /> .-> <br /> t <br /> Address_ _.. Cit ""` <br /> Y{:� .. :..--............. yip- - - _ <br /> A t-. <br /> Contractor's Name ...... - /S <br /> - � =: . . -......._License #.�_�_ --1--- ... Phone._-. .-?..�- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other.. - ..._..- <br /> Number of living units; _`...._ _ Number of bedrooms- ' ..Garbage Grinder......__ ___Lot Size... ,%`_ �^�-� _ <br /> Water Supply: Public System and name-- . ....... .Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam W 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 ..._ - ----Type---- .-- ..... Material ..........No. Compartments <br /> Distance to nearest: Well ...------ ______ _______Foundation........ _ Prop. Line.._. <br /> LEACHING LINE [ ] No. of Lines _ .. ...... --- of each line_..... ............... .. Total Length . _...._. <br /> D' Box Type Filter Material ...... ...-- Depth Filter Material-- _.-.------- <br /> Distance•to nearest: Well-------------------- -- - Foundation. --- ..---- -- - ..Property Line..... ------- ----..---- <br /> ..-------- <br /> SEEPAGE PIT [ l Depth.... - Diameter-_ ........... <br /> Number...-----.------- --------------- Rock Filled Yes F-1No [] <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[ _ <br /> Disposal Field (Specify Requirements) . $sa ' ` <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 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 becos bjeact to, kmar 's Compensation laws of California." <br /> � . /` . <br /> Signed--... (1 � <br /> ,.--. .. ---�--...-- .-Owner <br /> BY...... ........ ,� s! L title_ <br /> L _ _ <br /> {If other than owner) <br /> O D PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.......... c... rY�^� ­C.. DATE <br /> - __... <br /> DIVISION OF LAND NUMBER .. DATE . .. ... <br /> - -- <br /> ADDITIONAL COMMENTS . _..... _ _ <br /> - - -- - - - <br /> ---------- -----_ ....- . <br /> Final Inspection by:.. ----........ <br /> EH 13 94 AN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 9M <br />