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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------j�- ;- ---- Permit No.19_"A-1 o <br /> 1 1, (Complete in Triplicate) <br /> --------------------------------------------------------- <br /> Date Issued-------.------------ <br /> ---------------------..._______________________-_-__ 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 Rules and Regulations: <br /> ' ' - <br /> JOB ADDRESS/LOCAT N - ' �x .-,� � ENSUS TRACT - - <br /> _ -- - Phone <br /> --------------------- ------ <br /> Owner's Name------` -- . L --- Zip l- ZG --- ---- ---- - - - - Ci+� -- <br /> Contractor's Name-------- --- ---------------------License ----Phone--------------------- ---------- <br /> Installation will serve: Residence❑ Apartment House ❑ Com ercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---- ..... <br /> " <br /> Number of living units:----------------Number of bedrooms------------Garbage Grinder------------Lot Size________________________----------------------------- <br /> Water <br /> ___.________Water Supply: Public_ stem and name__----- ------ --- ---------------------------------------_,_ ---- _Private <br /> Character of soil to a depth of 3feet:/ Sand [_1 -Silt EJ -£fay-0- Peat-0 Sandy Loam-E] ClayLoam EJHardpan � Adobe E] Fill Material____.__-__If yes, type-------------------------------- <br /> (Plot <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 see ge pit permitted if public sewer is available within 200 feet,)- <br /> PACKAGE TREATMENT [ ] SEPTIC' E Size_�r_X/e_�"____ --------------------Liquid Depth- <br /> /-------------------- <br /> Capacity-,j_.b0_0--------Type _ _---- ----------Material------ Compartments-------------------/-------------a <br /> Distance to nearest: Well--- ---------Foundation-------;? /--------Prop. Line _51-------------------- <br /> LEACHING LINE [ No. of Lines--------- f <br /> Length of each line. ' - Total Length <br /> Box-----/-----Type Filter Material____S/_e-------Depth Filter Material__-__ ---------.______________________.___----_. <br /> Distance to nearest: Well _____147a-____`___.Foundation____LC2)__'__-____-___Property Line___',,,S---/------------- ----__. <br /> SEEPAGE PIT [I/� Depth__u2�/---Diameter..__- ----Number-----------3----------------- Rock Filled Yes Zl/ No ❑ <br /> Water Table Depth-----` I` ----- --11------------------------- --.Rock Size----/_� - sr-- -------------------- <br /> Distance to nearest: Well-------J. 'h�-----------------------Foundation-----/__f1----__----------Prop. Line------- �_______-___ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--__________.__________________-_______---_.Date____---_-________________________________) <br /> SepticTank (Specify Requirements)-------------------------------- --------------------------------------------------------------- ------------------------------------------- <br /> DisposalField(Specify Requirements)---------------------- -------------------------- ---------------------------------------------------------------------------------------------------711) <br /> ------------------------------------ - --------------------------------------- <br /> ----------------------------------- ----- ---- ----- <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 become subject to Workman's Compensation laws of California." <br /> Signed----------------------------------------- -- -,-------------- - Owner <br /> By------------------------------------------------ -- ----- ,-----Title------- ' <br /> (If other an owner) <br /> PPR,DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- 13 - - -----------------------------------------DATE.---,x-_27 <br /> DIVISIONOF LAND NUMBER------------------ ---------------------------------------------------------- ------------ DATE---------------------------------------------- <br /> ADDITIONALCOMMENTS------------------------------------------------------ ---------------------------- ----------------------------- ---------------------- <br /> ------------------------------------------------------------------------------------------ --- -------------------------------------------------------------------------- ------ <br /> --------------------------------------- - - ----------- -------------------------------------------------- ------ ---- ---------- <br /> Final Inspection by:---------i-- - �---------- -- -------------------------------------------------------Date. �� <br /> -- EH 13 24 SAN QUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />