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FC�t OFF,�CE USE: FOR OFFICE USE: <br /> AP.,lDLICATION FOR SANITATION PERMIT <br /> - - -------------------- -- t< . 7 7 9� <br /> 3 jj4r f (Complete in Triplicate) ermit No._ _ _ ____. - <br /> ------ ,"� <br /> Date Issued __ �.-_77 <br /> ........ _ _1__ ______________ _____________-_ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Healt4.Djstrict for a permit`fio construct and instalt'the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI r ____ ---- ____._. --------- <br /> -- - -- -------------------------------------CENSUS TRACT--------------- ----------- <br /> Owner's Name-------- - ------------- - --------------------- --------------------------------- : - - -Phone ------------- <br /> Address-------�:o��'�' ----------------------- `� � 1__ <br /> 1:7 Contractor's Name------- --*'-- -.--License ' ----------.--------,_------Phone------------------- <br /> Installation will serve: Residence❑ Apartment Ho se ❑ Commercial Trailer Court <br /> E]Motel F-1Other--------------------------------- <br /> Aff <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❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fi4l Material------------ yes, type----------------------___,______ <br /> v <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----ZV_2__4�_.L0�---------------------Liquid Depth._________-._ir-1 <br /> Capacity-1_pQ d-------Type__ _-----------Material---1&4-'I_________---No. Compartments----�_______________Distance to nearest: Well___1.►`l1________-_______________Foundation___IV--______________Prop. Line- <br /> ---- ----------LEACHING LINE [ ] No. of Lines_____ ---------------------Length of each line._ f.1_________________-Total.Length.--- ��_______________--- <br /> 'D' Box___-_._._Type Filter Material______________-.-_.Depth Filter Material---------_----------------------------------------------------- <br /> Distance <br /> _....-...__-.-_____________________.Distance to nearest: Well..-__._____.__L____.____Foundation____.____.____.___________Property Line------------------------------------ <br /> SEEPAGE <br /> ________________________ __ <br /> SEEPAGE P1� [ ] BepTh'�__.______-Diameter_4V .�X___umber______./.__._______-._____._ ` Rock Filled Yes N <br /> Water Table Depth---------------------------------------------------------Rock Size------1 <br /> r- ------------------------------ <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)-------- ----------- --------------------------------------- ----------------------------------------------- ------------- <br /> ------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------- <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 /> "1 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 than owner) <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ _�" <br /> -- ----------- - DATE.-/ -� --7 ---------------- <br /> DIVISION OF LAND NUMBER------------------------------------- -------- ------------------------------------------------------------DATE------------ --------------------------- ------- <br /> ADDITIONALCOMMENTS---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- <br /> --------------------------------------------- <br /> ---------------------------------------------- <br /> - - - ---------------- <br /> Final Inspection by:--��7.._ --. ___Date. -2' 1 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />