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TNW-r7 <br /> AOR OFFICE USE: FOR OFFICE USE: <br /> r APPLICATION FOR SANITATION PERMIT <br /> ----------------- -�2—�3 d <br /> ---- (Complete in Triplicate) Permit No._____ ___._______ <br /> ------------�-�-��`------ '�,-�---� Date Issued--- <br /> 4 <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 /> A116 <br /> JOB ADDRESS/LOCATION- c _._-_ Q-s__.________.___ -_ � N�V6N/ <br /> ScNbv� CENSUS TRACT_ --.-----------------------. <br /> '�A�,� <br /> - --- ---- - --- <br /> Owner's Name.-- �` hG-Cf !1 ----- -----` ------------- Phone_.. <br /> F <br /> ------ -----.City---- BGc>r. Zip- <br /> Address---- -r�J ? <br /> '-9/ p ---------- <br /> Contractor's Name-------------- -- - ----- ------_----------------------------------License # 5Phone--- <br /> Installation will serve: Residence E] Apartment House. Commercial F] Trailer Court <br /> ❑ ❑ <br /> . Motel Other----- r ---- --------------- <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 ❑ Fill Material------------If yes, type---------------------------s___-.__ <br /> (Plot plan, showing szeof lot, location otsAtem in relation to wells, buildings, etc. must be placed on reverse side.) 0 <br /> NEW INSTALLATION: : (No septic tank or zeepge pit permitted ifspublic ewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ )` SEPTIC TANK DC - Size`. __X_� _____ . ._-_-_ ------------ --I ____Liquid Depth-_� ._.._ _._. __ <br /> Capacity2*91"__a"C Type- Material-- - JNo. Compartments <br /> ./fes ---- <br /> Distance to nearest: We91:__-.-_/.� __ --------Foundation------- _f------Prop. Line---- -.----------- <br /> LEACHING LINE No. of Lines___ -----/--- ______ tent' sh of each line ___ _./_UZ2_____ Total Length.th .lam __ ------------ <br /> 'D' Box _ __Type Filter Matericil_f�40t-4_____Depth FilteF Material __ ._-_!-R __r------ <br /> -------------------------------------- <br /> Distance to nearest: Well___ .�d__�___--___Foundation_--_l_Q_._------------Property. Line__ _� + <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number_.e---------------------____- Rock Filled Yes❑= No ❑ • <br /> WaterTable Depth--------------- ----------------------------------------Rock Size------------------------------------------------ <br /> Distance to nearest: Well------------------------------------------'farmt#t'tion-------------------------------Prop. tine---------------------------. <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 /> 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------ ------ -- ----------- -- ------L,11 <br /> - -----------Owner y <br /> ----------------------------- <br /> By--------------------- - -------=-----------------------Title-------- - <br /> (I o er than owner) <br /> R DEPARTMENT USE ONLY <br /> gQ <br /> APPLICATION ACCEPTED BY-------------------------- -------------------------DATE.____1�_ - ------ 7-------------- <br /> DIVISION OF LAND NUMBER-------------------------------------------------- -------------------------------------------------------DATE---------------- -------------- <br /> ADDITIONALCOMMENTS-- - ------------------------------------- -------- -------------------------------------------------------------------------------------------------- ------------ <br /> ------------------------------ ----------- --------- ------- ---- -------------------------------- -------------------- ------------------- -------------------------------- -------------------- ----------- <br /> ------------- -- ----- ------ - ------------ - ---------------------------------------------- -------------------- - - -- - <br /> - ------------- ------------- <br /> --------------- --- - - - ` <br /> o Date -- - --------------------- <br /> Final Inspection by:------ - -(� / <br /> - , -- <br /> EH 13 24 SAN JOAQUIN LCICAL,HEALTH DISTRICT F&S 21677 REV. 7/16 3M <br />