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FOR OFFICE USE: _ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------- ----------------------------- Permit No --597 <br /> 2- <br /> (Complete in Triplicate) <br /> -- G <br /> /� Date Issued___________.__ <br /> -..______-- =T�__-_________ _ __ _ This Permit Expires 1 Year From Date Issued <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 ules and Regulations: <br /> Y _ <br /> JOBADDRESS/LOC ------------------------------------- ------------------------CENSUS TRACT.----- ---------------- <br /> _­0/ <br /> ---------- ------------ <br /> Owner's Name---- = / �`'- ------ ---------------------------------------------4 Phone - <br /> �� ----Zi _ -------------- <br /> Contractor's Name <br /> -------- � City - p <br /> � ` ,u_ License #��/5- �` -------Phone r_4� �- � <br /> Contractor's Name--------------------------------------- - ----------------------------- -- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Coopf ❑ <br /> Motel.❑ Other----------------------------------------' <br /> Number of living units:__,--------J_, � <br /> __Number of bedrooms_ _____Garbage Grind—er' __Lot Size__ ��1. _ ------------------------ <br /> Water Supply: Public System and name------------- --- ----------------------------------------- --- ----------------------------------------------__PrivateA <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Rill 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 j ] SEPTIC TANK ize___'��� ______________________Liquid Depth.�X_?__________ <br /> ----- o. Compartments.---- <br /> ------------------ <br /> om - V1 <br /> Capacity---� � ---.Type_ _ Material_ partments._--- ____-- <br /> Distance to nearest: Well____.______ --I____-.-_.______Foundation__:_/�_!_-______Prop. Line_______.___..__.__. <br /> . _. . <br /> LEACHING LINE [�ij No. of Lines __ ________Length eac line,._Y .y1_�C --__-.Total Length____ -�_________ ___.___ <br /> O <br /> 'D' Box-_ ` _ Type Filter Materia---------------------Depth Filter Material___-_ ___ _ _ ___ -_--_`� ----------- - -------- <br /> Distanc to nearest: WelL__.,�___--_� -_ ___Foundation -`�� -1__ ;___.__.._Property Line ____------------------------ <br /> __ _ <br /> / <br /> SEEPAGE PIT [�Depth_��______Diameter_`���>______Number___�---------------------_ Rock Filled Yes�o ❑ <br /> Water Table Depth-------- 7� /------------------- -.-----Rock Size_----- �?. 1 -�------------- -- <br /> Distance to nearest: Weal_______-/_�_1_________________Foundation_ -----------Prop. Line,-$�------------------% <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date.__________-.__.--___________--------------------------------- O <br /> Septic Tank (Specify Requirements)------------------- - - <br /> DisposalField(Specify Requirements)-------------i------- ---- --------------------------------------------------------------------------------------------------------------------.... <br /> ----------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 Workman's Compensation laws of California." <br /> Signed---------------------------- -- --------------- Owner <br /> BY--------- ------ //` T Title---- - <br /> (If other an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - `------ -----DATE----444 7-?------------------------------ . <br /> DIVISION OF LAND NUMBER_--------------- =-------------------------DATE--------- - <br /> ADDITIONALCOMMENTS----------------------------- ----------------------------r------------------------------------------------- ------------------------------- <br /> ---------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------- - -------- - - ------------------------------------------`--------------- ----------------------------------- <br /> FinalInspection b -- - -- ------------------------------------------------------------ --------------------------Date-- 90- -/ <br /> / _ .. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/76 3M <br />