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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------- �� 6y <br /> - -- Permit No.________________._ <br /> (Complete in Triplicate) <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 /> fCCENSUS TRA <br /> CT_--------------------------------- <br /> JOB ADDRESS/LOCATION - ' <br /> i4 . - ;PhoneOwner's Name---- ---A ---- ! -- , --------------------------------- <br /> Address--- -------- ----- ----- " (^i _ r <br /> �U_- Ci a <br /> P <br /> Contractor Name__,_ :__ �� / <br /> ""t-' e ' / ----- ---- -------- - <br /> ---- ---License Phone y <br /> Installation will serve: Residence-0 Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------------------------- ------- _ <br /> ` J <br /> Number of living units:-----(---------Number of bedroom-_-----Garbage Grinder-.- ------.-Lot Size------. _>e� -_%.-.---------__-_ <br /> Water Supply: Public System and name IA/Z-I-�---=----------C�/1 - - 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-_------------------_-_---._ <br /> (Plot plan,•showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTAXIATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE-TREATMENT [ J SEPTIC TANK [ J Size-----------------------------------------------------------Liquid Depth_--------------_---_----- <br /> Capacity---------------------Type-----------------------Material-------------------------No. Compartments_--------------------------------- <br /> Distanc!Z)Io.nearest: Well-------------------------------------------Foundation--------------------------Prop. Line---------------------------- <br /> LEACHING <br /> ---_. -._LEACHING LINE [ J 'No, of Lines---------------------------- Length of each line------------------------------Total Length.-_---._._--------.----_------------- <br /> 'D' Box-------------Type Filter Material--------------------Depth Filter Material-----------------------_------------------------------------ <br /> Distance.to nearest: Well----------------------------Foundation----------------------------Property Line----------_-__.-----__----_-.-__. <br /> SEEPAGE PIT [ ] Depth-----.----------Diameter-------___-__-._-__,Number-------------------------------- Rock Filled _Yes❑ No ❑ <br /> WafterTable Depth---------------------------------------------------------Rock Size-- ------------------------------ <br /> Distance to nearest: Well------------- ----------------------- ------Foundation--------------------------Prop. Line---------------_-.--.-----. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date`�' -..-.---._------------_--- <br /> Septic Tank(Specify Requirements)------------------------------------------------------------------------------------- -------------------------------- --------- <br /> 7 _� <br /> Disposal Field jSpecify Requirements)___.-_._ - _ ..__ - "_.-.-.--._--.---.----------- <br /> ----------------------------------------------------s----------------------------------- <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, ar-dF',R les and- Regulations of the San`Joagein 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 sublefy t ' Workma s -Compgnsation laws of California." <br /> �° �'rv4... <br /> Signed-}----- } `-------- �e%'� - ----- ---:---- -----------Owner <br /> By----------------------------------------------- -=------ ------------------------------------------------Title.---------------------------------------------------------- -------------- <br /> 1If other than-owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- c - --------------------------------------------------------------DATE.---- ---r - <br /> DIVISION OF LAND NUMBER. - ------------------- DATE - <br /> ADDITIONALCOMMENTS----------------------------------------------------------------------------------- ---------------------------------- ---------------------------------- <br /> ------------------------------------------------------------------------------------------------------------ ------------------------:----- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------ ------------------------- - -------- ---------- <br /> Final Inspection by:.- - Date --------- <br /> FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 216W/76 3M <br />