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FOR OFFICE USE: - FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------- ----- .2- (Complete R (Complete in Triplicate) Permit No._�._.-__._._.___. ---------------------------------------- - - - Date issued- ---�--- --- --- ___________________________________________._.______.__ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: } JOB AD'DRESS/ TION:_: _.. ��_.-- Lt-.'- .------��_-- -�-�'------- ---- -----------------------_- -- -CENSUS TRACT __-_]---- -- Owner'.s Name- l)Ct_ .............. -------- -- --- --- ------Phone----1�- ---------. -------------- a-i ---- zi r Address-.' h �0�/� t'b b +DG- tY - ��, p ` Jam., Y .j Contractor's Name .--- ------- 1�--[ ------------------------------License #_c. Phone---�i �_ _ -- Installation will serve: Residence 0-,' Apartment House.D Commercial Wgo- Trailer Court. ❑ - = Motel ❑• Other--------------------------- ------------ - - Number of living units:________'___.__Number of bedrooms____________Garbage Grinder_„__,_;_._._Lot Size__ ,e . .0/_� - ---___,- __________ Water Supply: Public System'and name__ � . .____.4�=w_..................... -- ---- _ ------------------ ----- Private ❑ ��gg . - Character of soil to a depth of 3 feet: F Sand ❑ 'Silt❑ Clay ❑I' Peat�5`andy-�Loam ❑ iClay Loam ❑ ... F Hardpan E] Adobe ❑ Fill Material._..__b-_ if yes, type_-_'��___________________I { .- {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be'placed on reverse side.[ NEW INSTALLATION: (No�ctsee age pit permitted if public sewer is availab e within 200 feet,]PACKAGE TREATMENT O [ ] Size.---�--- -- -- _ -_-------_-__-- _-- Liquid Depth -- -------------�- - Capacity __- _ ;Typeh- T_ r� ` wMater.ialTr__ -_ L -_No. Compartments.-- .----------- -------- - . I -- . -.Distance to nearest: Well_______________________________ �. ___Foundot an._._� _#__i_.___-_:_Prop. Line____x i -- I LEACHING LINE [;) No.,_of Lines_'-.---.-------------------_._ .Length of each_line!----- -f__-_------:,.Tota l.Length.y___..__,_____'------------------------ it -- -- pr _ 'D' Box--=------ --Type Filter Material----------------- epth ? F �� t ----Foundation '----- [ = Pr Fi Iter.hAatenal___.___._ I :Distance to nearest: Well-:------"------'----�._ ``"`"' Property Line------------------------------------ SEEPAGE PIT [ ) 4 Depth -----------Diameter_. __ .. ___Number_: _� _ Rock Filled Yes ❑ No❑ f Water Table Depth- _ :_ r?Rock.Size._.___ _ l . .c 1. "� '; } :-- a-- - -F'ourtdation •� -Prop. Line- --- ------ ------------- REPAIR/ADDITION $ Distance to nearest: Wel]_;.___ __. � � _� # (Prey.'Sanitation Permit#-- ._ -------- °---.Da e-- -- --------- �- . ---=----`----} I. Septic Tank [Specify Requirements] - ► = - = - = >w ==---------- =----------- -------=- ------------'--- Disposal Field (Specify Requirements).----""--- ----- = '-------------------t --------- ------ �1---------------=------=------------------------------------------ ------------------------ = .. _ - ------------------------------------------------------ , . .. w -------------------------------------- ------- I =----------------- - -------------------- ---------------- ----------------- --------- --- ,- --- - -- --- -- (Draw existing and required addition on reverse side) I hereby certify that.1 have prepared`this application-and that the work will -be done in. accordance with San” Joaquin'County Ordinances, State Laws, and Rules' and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: : r � f "I certify that in the performance of the.work for which this'permit i+ issued;-,i sFiall�not employ any person in such manner as to become .subjec o. Wor an's Compensation laws of California.'.-. Signed-, r Owner ' --= __" ------- --------------- - ' # r F I. (If other than -owner)-. � 4 FOR QEPART NT USE ONLY' APPLICATION ACCEPTED BY_____________ ' ' �' .� . - -------------DATE.- -- --------------- - DIVISION OF LAND NUMBER`..----= ----- -------- ------------------ -- - ADDITIONAL COMMENTS------------ - ---- --------------.--------- --------------------=- ---_---- -- - ---- - #----------------------------------------- ... ----------- ----------------------------------' --------- ----T-----"---------------------------- -------------------------=------------------------ ' f-------------------- ----------------- ----- -- - Final Inspection b �-`. Date._ -- _ _ �..,. ;l ' p Y '= ------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677,,REV. 7/76 3M