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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------- --•---•------............. <br /> `• {Complete in Triplicate} Permit <br /> --------------------------- ------------ - -- <br /> ............... m Date.---• ------. ...--..---.--.------ This Permit Expires 1 Year FroIssued 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 OrdinanceoNo. 549 and existing Rules and Regulations: <br /> YAIN JOB ADDRESS/LO -... <br /> ..�- -•- ------ -------• ---------- ----------CENSUS TRAC- <br /> T.--.---•-'--�--•----..'.�..--- . <br /> Owner's Name.. t�........ --• •-• ...---------.-- •--- • --Phone-� <br /> Address. � -- ------------ <br /> 0--77'--------- ..........Ci Q <br /> - <br /> Contractor's Name--- --- .... � License #----------- ------ Phone------ ... ---- . <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_......_........ .............. <br /> Number of living units:.......--- "._.Number of bedrooms....-_—Garbage Grinder.....O..Lot Size ........... �._.� - �....... .: .. .. <br /> Water Supply: Public System and name --------------------- ------------------------------ ...........-•.............. ----------------------.Private ❑ <br /> Character c� soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay Peat ❑ Sandy.Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill MateriaC... -_ 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> I <br /> PACKAGE TREATMENT [ ] SEPTIC TANK �� <br /> ' Size....... ,�p -------------------Liquid Depth.. ------- <br /> Capacity ..... - ------Type............. .......Material- -----.. ��� -..No. Compartments-----. '... .... <br /> --- ff <br /> Distance to nearest: Well_...-- - 1.. _-Foundation.:/1?..........Prop. Line---19119...:.....:....... <br /> LEACHING LINE [ ] No. of Lines _..' - ----:......L�g h of eac ine ...................... .....Total Length .. f <br /> i : <br /> D Box..._...:....Type Filter Mat -� . - pth Filter Matgrlal...---...-. ................_..-----.----_.... ....... <br /> Disptance to D e rest:. eter- �.�. ...Num'ber Foundation--- :................Property Rock Filled Yes N <br /> SEEPAGE PIT [ ] De th.�� i . ... )] N ❑ <br /> Water Table Depth.------•------- - Rock Size.- - --- /9--............:..... <br /> V--f--�----- ----------------------- <br /> 'i � ....................... <br /> Well. Foundation. --..-- - p, __.. _....-. <br /> REPAIR/ADDITION (Prey. Sanitation Permit#....... -� . - ---------Date_------- <br /> Septic Tank (Specify Requirements)-- ------------------------------- -- -----------------------. ----------- ------------------- ...........-.......... <br /> C <br /> Disposal Field (Specify Requirements).-. .......... ------------------------ --...................................................... ............•---.. ...........................C <br /> ....----• ---------- -------------- .........- - .........------------------------------....7- ................• -------•--------- -----. .-- - •.. ...................... <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 /> Y <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 becomesu�to„N(orkman Compepsation laws of California." <br /> Signed---- ��...� < ------ ---- ----Owner <br /> By......................... ----.,Title........... .............................. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.......... ..... -------------------------------------DATE 3 f.Z�.�.� --------- <br /> DIVISION <br /> -------DIVISION OF LAND NUMBER.......... .... ... ...... . .......DATE.... ..-----...-- ..._... . . -- . <br /> ADDITIONAL COMMENTS-- <br /> i <br /> k .. ........................ .... ... .. ---- ---- <br /> .- --....-.-.-.................:.................... .....-.._ -- .•.-.......-•_......._.......-...-._..............--•__.-..-...-...--.........._•-------•--.......-......-------...----..........--__•_ <br /> ------------------............... ........................ k a«------.-.._..-..........-.........-.-......----------------------- .---- ..-..._..--.-.__._........... ... -..... <br /> Final lnspectlon by.....- 1 ---------=---- .------.•..--- ----.-...---Date... '.-2z.- .�......_... ...... <br /> EH 13 24 SAN JOAQUIN LOCAL,-HEALTH DISTRICT f&S 21,677 REV, 7/76 3M <br />