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L FCR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - --- -- --------- <br /> (Complete in Triplicate) Permit No.___7__________________ <br /> ' -------------------------------------------------------- <br /> Date Issued-._�_______ <br /> .-.--_____-_______________________________--.-.-.---.-- This Permit Expires 1 Year From Date Issued <br /> - r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install thew ork herein described. <br /> This application is made in compliance with County Ordinance.No, 549 and existing Rules and Regulations`: <br /> JOB ADDRESS/LOCATION-... Q --------------CENSUS TRACT---------------------------- <br /> Owner's Name <br /> --- e ---------------- Phone. <br /> Address---------------------�'`- ------- .4f -- `------------------------ -- --------- <br /> -- �/ <br /> . City.:--- -- � - - - Z�ip---� --- ----------------- <br /> Contractor's Name ------ --------------?---- License # -X73_Phane_ l�' � �� <br /> Installation rWill, serve: ResidenceApartment House.❑ Commercial ❑ Trailer Court ❑ <br /> >.., -„ i .. Motel F] Other---------------------- :---------2- ---- <br /> Number of living units:_,_-f------____Number of bedrooms--.r1Garbage.Grinder__.=___-_._:_Lot Size.--..6,----_-X__� -,.-:---.----------------- <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 /> i <br /> Hardpan ❑ Adobe ❑: Fill Material---.-_---.--If yes, type____.---_------- ------------- ; Cr <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) C <br /> NEW INSTALLATION: 'No,septic a kor seepage pit permitted if public sewer is available within 200 feet,) 4 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size___---------- --------------------------- -------------Liquid Depth.-.---.---.--_.--._- <br /> ~' ICA <br /> Capacity----, '---------- ---Type---- ----:-------------Material--------------------------No. Compartments-----------------------.-------- <br /> - -------------Len Length of each line.-----------: ---_- --------------------------.Prop. .Line--------------------------- <br /> LEACHING <br /> ------ ---------------- x <br /> Distance to nearest:WeII_------__-- -------- -_ --. -Foundation <br /> LEACHING LINE [ j No. of Lines--'-.--.---- - � <br /> g -:-.---.Total Length _-._------------------------ <br /> 'D' Box--:--------Type_Filter Material--------------------Depth Filter Material------------------------------------------------------------. <br /> Distance to nearest`. Well------ -------- ------Foundation---------------------------.Property Line----------------------------------- <br /> SEEPAGE <br /> ------SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number------.-------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth-----------------=-- ----------`-�:��-------.- Rock Size------- = =----------------- <br /> Distance to nearest: Well----------------------- ------Foundation.-------------------- ---Prop. Line------------.------.-------_. <br /> I' REPAIR/ADDITION (Prev. Sanitation Permit#-..------. ----------------------------Date-------------------------------t--------------] <br /> Septic Tank (Specify.Requirements)= t -- -------------------- =----------------- --------- <br /> Disposal Field (Specify Requirements)­­,--ldG , <br /> Y ...- .____-,...�.�-- . <br /> ` I s ¢ .�A u L i <br /> (Draw-existing and required addition on <br /> - -------------------. .. : 6------------------------------------- <br /> -----=----------------------- -------_----------.-- •-i <br /> reverse side) i <br /> I hereby certify that I have prepared this applicat on,and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulaaions of the LSan_J.oaquin,LocaI-Heaith-District,.Home owner or licensed agents <br /> signature certifies the following. ti,t - : <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 /> toI become subject to .Workman's Compensation-laws of California." <br /> Sig ned--- ------ -------- -------Owner , <br /> t <br /> BY-=----------���1� ------- � � ` ------------------------Title -- -- --------- ------------------- <br /> (if <br /> --- - -----------(If other than owner) . ' <br /> j FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.------- - ------------------------------------------------------------DATE r ---------- ----- <br /> --- --- -------- '> �. ---- - <br /> DIVISION OF LAND NUMBER ---------- ----- ----------DATE------ ---------------.---- _-- <br /> -------------------- ----------------- <br /> ADDITIONAL COMMENTS------------------------------ <br /> ------------------------------------------------------------------------------------ <br /> -------------------------------------=--- --- ---------------------------------------------------------------------- <br /> ----------------------------------------------------- <br /> ----------------------- --- ------------------•----- ---- -P <br /> -------- ----------------------------------------------------------------------- r - <br /> Final Inspection by:--------_ _-,- Date.--- -.-�- - __ . <br /> =. /W <br /> I er+ 13 24 JOAQUIN LOCAL HEALTH DISTRICT Fos iib» Rev. <br />