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die <br /> i <br /> FOR OFFICE USE: FOR OFNFc t: Ust: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------- { <br /> , .,�.. Permit No ... <br /> (Complete in Triplicatel�'� � ..."........... <br /> Date Issued. '' J' � <br /> ................... ............................... This Permit Expires 1 Year From Date Issued <br /> i <br /> ,!...:26 �wA-y� t.2... <br /> Appl cation is�lereljy mcide to the Sfn Joaquin Local Health District for a permit to construct and install the work herein described. I <br /> This application is made in compliance with County Ordina a No. 549 and xisting Rules and Regulations: <br /> t ir � . <br /> `- � CENSUS TRACT_..OSS -h30-�s <br /> JOB ADDRESS/LOCA I N __. .-. <br /> Owner's Name_-- <br /> ...---� ------------ ---------------------------- --- -- - -- -------------Phone.- --�---------------- - <br /> Address--------f� ..... - -- .! --- ._ -_. . ......CitY ............. zip-=-_.......................... <br /> Contractor's Name.... .................... License #.. -.Phone. ��.` _� - <br /> ... . <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ <br /> Motel ❑ Other... _... <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 ❑ PeatV Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 0 Fill Material.. .... ....If es, type................................ �+ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) T y� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted kf publ� sewer is available within 200 feet,) ` J Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] S. 6K 15-7 /� Liquid Depth. -...... <br /> ��--�------- ---- - - <br /> Material.-- <br /> No. Compartments. CA— <br /> .......................�__ <br /> Capacity �. V. TYpe .... ��- 'v <br /> Distance to nearest: Well..�.�?1-_-----......_..._...---Foundation.�2dV�.+'.....Prop. Line_��.. <br /> LINE [ ] No. of Lines.................-......-•-..Length of each line------------- Total Length .. .....--..............__...-__-: <br /> NG } <br /> L ACHI '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 /> Water Table Depth----------------------------------- ---------------------Rock Size------......... ------ ---------------- <br /> Distance <br /> ------------ -- <br /> Distance to nearest: Well................................_.-.......Foundation.-.----------.............Prop. Line--......------------ <br /> REPAIR/ADDITION <br /> --.__---- -REPAIR/ADDITION (Prev, Sanitation Permit#-------------... .- ........ ..____.._....Date.-_...... ....-_- <br /> Septic Tank Requirements) - ---- ..-------- ° i;•. <br /> t <br /> Disposal Field (Specify Requirements)............... <br /> -- ---- -------� <br /> .............. ............... ----.......-----....... ------ ---------- ------- --- -----------•--- -------...... --------------------------- -­------------ ...... <br /> ------------------- ------ - <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> Ordinances,- State-taws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agent;. <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' ompensation laws of California." `,'t <br /> Signed---------- �. --Owner �] <br /> By........... -- - ------ ------------ - -- t _....+... ... . -.........Title.. 4 i <br /> (if other than owner) T <br /> T <br /> FOR DEPARTMENT USE ONLY E° <br /> APPLICATION ACCEPTED B . .. . .. - -DATE <br /> ........ - - _..... <br /> DIVISION OF LAND'NUMBER---------- ----------...................... ------------DATE ------.................... ....-- .........€ <br /> ADDITIONAL COMMENTS_...------- . ------I,.--.... -- - <br /> _ i <br /> ----------------------------- ------------------- ---- - ----...--- ... ------------ ------------------------------ ---................ ------------------- ...... <br /> ----------------------------------------------------------- ---------------------------- -------------------- - ----- „ <br /> ---------- ------- ---------.. ......... --- <br /> Final Inspection b WAJ <br /> --------------------------------------------------------- - <br /> - -- ------ <br /> Date.. <br /> EH 13 24 UIN LOCAL HEALTH DISTRICT FBS 21677 REV. 7176 3M <br />