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- FOR OFFICE USE: <br /> APPLICATION! FOR SANITATION PERMIT <br /> -- --- -- ------ -------------- ---- ----- ------------- �;* ; '�-" �.,` � , Permit No: ---�-----~-�-`�� <br /> ,Complete in Triplicate}t ' _, _ _ _ <br /> ----------I------------------------------------------------ <br /> Date Issued ._�_' �`7y <br />' <br /> ----------------------------------------------------- This,Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San.Joaquin Local Health District for a per to construct and install the work herein <br /> described.`This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB -ADDRESS/LOCATION . ..... -------------------------------CENSUS TRACT -------------- ----------- <br /> Owner's Name ------ �c`T' -- -- ----------------------------------------- --=---------------------------------Phone------------------------------------- <br /> Address � �L ' ------�� r�� "�------ ----------------------------------------------. City s--------------------------------------------------------- <br /> ;> <br /> ---- - <br /> ----------------- ----- <br /> > r. <br /> I Contractor's Name - - ________________________________License # `-- �- -- Phone <br /> Installation will serve: Residence ❑Apartment House-[] Commercial :❑Tra_iler,Court ❑_ <br /> Motel ❑Other ----- ----------------------------_ <br /> Number <br /> ---------- ---------- <br /> Number of living units_____________ Number of bedrooms ___?------ _Garbage Grinder ------------ Lot Size ------------------------------------ <br /> Water Supply: Public System and name -------------- M--------- ---` ----------- -------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ `Silt❑ t,�Clay E] Peat E) Sandy Loam ❑ Clay Loam;❑ <br /> Hocdpan-❑V- Adobe ❑ Fill MatFrial ------------ 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 /> I NEW,INSTALLATION: (No'septic tank':or seepage pit pdrFnitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ] Size__ f_ __A�l 2'_____________________ Liquid Depth ---Y'. <br /> Capacity __ -------- Type _____ Materia l_ *xfjrp ___ No. Compartments ------_________ <br />! Distance to nearest: Well _.___�3_b_'_________________ ______Foundation Jam`_______-___ Prop. Line ._....5'`__ _.------ 0 <br /> 1 --- <br /> t 'n <br /> --------LEACHING LINE [ ] No. of-Lines�-�r`_!___.______-______ Length of each Iline----_11`x________________ Total Length ,____..___•__-. �7' <br /> ty <br /> - <br /> 'D' Box � Type Filter Material __i _ ______Depth Filter Material _____�✓r`�---------_-------------- ________ <br /> Distance to nearest: Welf __. '_______________ Foundation ----/P Property Line __s" '____ __._.__- <br /> SEEPAGE PIT [ ] Depth --------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No C] <br /> �7 <br /> Water Table Depth --------------------------------f----------------- SizeF <br /> -----•---- <br /> Distance to <br /> nearest: Well ---------------------- -�-•------------Foundation -------------- <br /> ----- Prop. Line # --•--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -.-----•------------------------------------ Date ---------------------------------- d <br /> Septic Tank (Specify Requirements) ------------------- <br /> Disposal Field (Specify Requirements) ----------- -------------------------------------------------------------------------------------------I-------- <br /> l 3 <br /> ---------------------------- -- ------------------------------ --------------------- ---------------------------- <br /> jDraw existing and req 'on reverse <br /> red <br /> id <br /> Ihereby certify that I have prepared this application and Ithatafideitiwork will be s <br /> ----------------------------------------------------- <br /> - ------ ---- ----- -- dane in accordance with San Jo <br /> --- <br /> aquin <br />! County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. home owner or licen- <br /> sed agents 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 <br /> as to+become sub)ect to Workman's Compensation laws of California." <br /> Signed -- -- ---- --- - ---- ------- - - - --- --- -- - - ----- ---- r--------- Owner i <br /> -- <br /> By -- Title <br /> t (If other tha owner) } <br /> a AOR DEPARTMENT USE ONLY �I <br /> APPLICATION ACCEPTED BY ----------------------------------------------- ------------ DATE _. l �7 tf----------------- <br /> BUILDINGPERMIT ISSUED ---- ------------------------------------------------------------------------------- ------------ <br /> -------DATE —1—ADDITIONAL COMMENTS ------------------- ------------------------------------ --- ------•--------- ------------------ [-------- • °-------- <br /> ----- <br /> 1-------------------- ------ -- --- ------------ ----------------------- ------------------------------- --------------------------- <br /> -----------------------------------------------------------------------------------------------------------------s•------------------------------------------------& ------------------------ <br /> --------------------------------- <br /> - Final Inspection by: ---. --- ------------ ----.Date --- - --�--- --------------------- <br /> j%. <br /> ------- ------ <br /> " ;� SAN JOAQUIY-19CAL HEALTH DISTRICT <br /> E .H:;9 .1 68 Re SM!yg ,.s ".. .. e ,: • <br /> . . . . <br />