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i ''-FOR OFFICE USE: - FOR OFFICE USE: <br /> APPLICATION FOR-SANITATION PERMIT <br /> ------------------------------------------------ Permit No. <br /> {Complete in Triplicate} <br /> --------------------------------------------------------- <br /> -------------------------------------------------------- This Permit.Expires 1 Year From Date Issued Date Issued___ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructand install the work herein described. <br /> This application is made in complian�c with, unty Ordin ce No. 549 and isting Rules and Regulations: z v@q <br /> JOB ADDRESS/LOCATION. S.s"'7 ---------.CENSUS TRACT----------- -- ---- ---- ------ <br /> Owner's Name [ ----------------------------- - ----- -------- ------ -----------------Phone----------------- ---- _-- ---- ------ <br /> �+t"J -- <br /> Address. --------- . City - --------------------- Zap-- :�.--= <br /> :. ----------- - ------- <br /> - ---------------------------- <br /> Contractor's Name___--___ _. _ . ��_ License #_ [� /..- --Phone___ f _T_ <br /> Installation will serve: Residence Apartment House F] Commercial E] Trailer Court [IM tel ❑ Other--------------------------------- --- ------- <br /> Number of living units_____ ____ Number of bedrooms----A---Gar a Gnder------------Lot Size--- - _�.- ------------------- <br /> Water <br /> _____.____.____Water Supply: Public System and name---- ------------­-- <br /> --- --- ----- ---------------------- ----------------------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,wieils, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted.af public sewer is available within 200 feet,[ <br /> fr-- � l' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size_,'_ �__ f _____________________ Liquid Depth___-- <br /> , - A ------------------ <br /> Capacity-1-AC-0ca <br /> _._Type- __-- Serial__-- T ��zZ_---------No. Compartments---�----------------------- <br /> Distance to nearest: Well__ (/ - F undation--__� p. 11 ,J <br /> - ---i- -- - -�--- - �� --=�A�-Pro Line---- --------------------- <br /> - -LEACHING LINE [ ]ANo. of Lines_I__0_.�_,90' egg ____________.Total Length._� _,,---------______________ <br /> 'D' Box----/-.-_-Type Filter Material__ __.Depth Filter Material__-_/ -- __"_.------------------------------ <br /> Distance to nearest: Well Foundation.... -Q------------------Property Line------- <br /> --------------- <br /> p __ / "�� � Rock Filled Yes No ❑ <br /> SEEPAGE PIT [ ] De Depth- ---------�__�_____Number.__________________ <br /> Water Table Depth Rack Size -------------------------- <br /> Distance to nearest: Well__--___._ _________ ____Foundation- -- `_---- - .________.Prop. Line-------------------------- <br /> REPAIR/ADDITION {Prey. Sanitation Permit#----/__________________________________�________.Date-____- __--`'______--'_ ___ ---- <br /> Septic Tank (Specify Requirements)------------------'----------------------------------- ; ------ -- <br /> Disposal Field [Specify Requirements]------- --- f - -------------------------------------------- <br /> ---------- <br /> - <br /> ------------------------------------------------------------------ ---------------------- ------- - -- ------------------------------- ----------------------------------------------------- <br /> r � <br /> . <br /> {Draw exi.sting.'and required addition-on reverse side] _y <br /> I hereby certify that I'ha;e prepared this application and that,th3e work will be``-done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the S n.Jgaquin Local-Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the workifor which this permit'Wlssuecf, I shoill not employ any person in such manner as <br /> to become sub'ect`to Workman's :Com�-ensat�` laws of CCalifor ia..'n� <br /> 1 p ' <br /> Signed.------- ---- --- -- - <br /> BY ------------ s .Title ' -t <br /> - --------- ---------- --- ----------------- --------------- <br /> [I oth n er {, <br /> FO EPARTMENTILISE ONLY <br /> APPLICATION ACCEPTED BY-­,e-0-1 " <br /> -- -- ----------------------------'------------------------ DATE.. 7 <br /> DIVISION OF LAND NUMBER.--------------- -- ---- .� -- ----;---------------� -- -------DATE -- - ----- ---- ------------------ <br /> AD Tl NAL�SO,MENT -_ '"__ <br /> ��7� lr---- - d ��G` wire +-�5�1r-t - rv� ----- ----------- <br /> Ile J <br /> ------ ----(-err{ -�--- 1"", =ll.�ra �JiS ��- - �/��' �1 - __Gal <br /> ------------------ ?- ------------ <br /> Final lnspectfon by >���SAN _ _.� <br /> ' <br /> A -- --- --- --- - ---£---:-`------------------------Date <br /> EH 13 24 JOQUIN <br /> LOCAL HEALTH DISTRICT F��1,ey> Rev. 7fe <br />