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FOR OFFICE USE: FOR OFFICE USE: <br /> -------------------- ----------- <br /> APPLICATION FOR SANITATION PERMIT <br /> - <br /> (Complete in Triplicate) Permit <br /> --------------------- ----------------------------------- 21 7 <br /> Date Issued-- <br /> ------------- <br /> ---------------------------------------- ------- - ------ <br /> ssued-- .--`.-.--.-..------------___------------------------------------------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT10 I _� .. �� CENSUS TRACT- ------------------ ----- <br /> Owner's Name-------- ,� <br /> --------------- ------- Phone -���� "�aL <br /> Address - - ; [ --------------- <br /> ------------ --- City ------. -----------Zip------ ---------- <br /> ----- <br /> Contractor's Name.-_. /l / ----- 1_License Phone-------------------- ----------� <br /> Installation will serve: 4 Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ I <br /> r Motel ❑ Oth r-------=------- -------------------------------- - Vi <br /> Number of Living units:__-.__/------_Number.of bedrooms__.- --_"."Garbage Grinder-.----------Lot Size---------------------------- ""-._______- _---.--_ <br /> Water Supply: Public System and name----------------------- - -- ----y-------_---- ---- ----------- ----------------------------- ------Private <br /> Character of soil to a depth of 3 feet: Sand [-] Silt ❑ Clay E] Peat EJSandy Loam ❑ Clay Loam ❑ ' <br /> Hardpan- Adobe ❑ Fill Material-----------_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.) t <br /> NEW INSTALLATION: (No septic tank"or seep a pit permitted if public sewer is available within 200 feet,) <br /> 60 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size _- �---- <br /> ----- -------------------------Liquid Depth-- -----:------------ ---- <br /> �µ r R <br /> t capacity f11�------ <br /> --- Type- -{ -Mater,ia.l------ ----.- o. Compartments-------------------- <br /> ------------- <br /> ----- -'-__Foundation-----16� <br /> r Distance to nearest: Well____ _______��` � � �� ---Prop. Line-.------.-" <br /> ------------- <br /> LEACHING LINE [ i No, of Lines-'_,__ , ---------- of each line _________.Total Length _,_f ---------_.-- <br /> t 'D' Box------_----Type Filter Material--------- " ---Depth Filter Material----------- ---.------------ ------------------------------- <br /> Y ,. <br /> Distance-to nearest: Well-s_ Foundation-------,/0 ___.Property Line--._____ �---------. <br /> SEEPAGE PIT [ Depth._ ---.Diameter__.- 2_`-____Number--------- -------------- -- —_ Rock Filler} Yes`�Y] N <br /> 4 Water table Depth.--- ---<-------- --------- --- Rock Size--- ------------------ ! <br /> Distance46'nearestc Well_'____ _ � -~___,__"___.Foundation_____ `-.Prop, Line.-- ------------------ <br /> REPAIR/ADDITION <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------------------------------------Date------------------------------------------------j <br /> SepticTank (Specify Requirements)--------------------------------------- --------------------------------------------------------------- ------------------- ----- ---------------------- <br /> k <br /> Disposal Field (Specify Requirements)------------------- - - ----------------------------- -------------------------------------------------------------------------- <br /> ----------- ---------------------------- ------------ -- ------------------------------------------------ ------ <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations_ of•the San Joaquin Local Health District, Dome owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to kman's Compensation laws of California." <br /> } <br /> Signed-_._ . , ------"Owner <br /> Title ----=------ -------------------------- <br /> By-------------------------- <br /> (If other than owner} <br /> 4 FOR DEPARTMENT USE ONLY <br /> A. <br /> APPLICATION ACCEPTEDBY- -----------------------------------=------------ --------- -------DATE. '--2 -------------------- <br /> DIVISION OF LAND NUMBER---------------------- - ---------------------- -DATE-------------7vrt�,------ -----------------y <br /> ADDITIONALCOMMENTS---------- --------=---------------------- --------------------------------------------:------------------------ ---- ------------------------------------------------- <br /> -----'-------------------=--------------------------------=---------- -------- ------------=------------- ---------------- -------- ---- <br /> ---- <br /> I <br /> -- ---- -------------- ----- ---- ------------------ -------------------------------------------- ----------------------------------------------------- -------------- ----------- ------- <br /> ------------------------------------- <br /> --------------------- -------------- ----- -------------------------------------------------------------- --------------------------------------- <br /> n <br /> Final Inspection by---- G• = <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT - Fas 21677 REV. 7/76 3M <br />