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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- �- <br /> --------------------- (Complete in Triplicate] � Permit <br /> ------------ ---------------------- 01 <br /> Date Issued____.__ <br /> ------------------------------------__-.------ --------- 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/L TION.o �i- a _ ` �� CENSUS TRACT <br /> Owner's Nam -. ..- - cam ------ ------- ---------------------------------------------Phone----- .---------- ---------------- ---- <br /> 7:> <br /> Address �- City - ------------ZiP2'� ��---'------ <br /> Contractor's Name - _ --A------------License #__3.z8 Z� Phone <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------' <br /> s r� <br /> Number of living units:_.-__�-.--___Number-of.bed�ooms-- -._.Garbage Grinder------------Lot Size.-----___.- r±-- -s ---------------- <br /> --------- <br /> Water Supply: blic System and name_f ---_�.E--r_____-_-_!__.___- <br /> pp Y� PuY -------------------------------- <br /> ---- -----:------- - -------- - - --------------------------------Private <br /> r <br /> Character of soil to fa depth of 3 feet.- Sand F1 Silt Clay Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> �- <br /> FiardpanaF Pdobe,❑ 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.) 110 <br /> . � � <br /> NEW INSTALLATION: "(No,rseptic__tank'or seepage pit permitted if public sewer is available within 200 feet,) <br /> i <br /> PACKAGE TREATMENT [ ]�"SEPTIC TANK ] Size- -�.X__`�__` __ - --------------------Liquid Depth <br /> LJ _ f <br /> rype Material__. No.-Compartment s <br /> --------y---- <br /> ----. <br /> Diance' a- rest. Well. � -�--------------Foundation.----fbProp. L ------------- <br /> 5�LEACHING LINE No. of Lines '----.- ---------------Length of each line---------`/a-_//--ff--- Total Length.----/ _ ---------------:----tet <br /> 1 <br /> th <br /> - DistaD ce'to�Barest:Filter <br /> WeII. �e Material _----� undation.ilter Material ---=.-.Pro ert --Line . -- - ,f '. ------ -----`---} <br /> . r /�. <br /> k r -.-Property ------------- <br /> -------SEEPAGE PIT [ Depth-19`_/h1Didmeter____•�_ . <br /> --------Number---`--------0------------- Rock Filled Yes No <br /> Water Table-Depth 5--------- E Q Rock Size - ----- '= <br /> Distancetonearest: Well_i _-----t-0-0r. -f'-------------Foundation__;_-L-d !" Prop. Line__ -_..------. <br /> t <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---t`----.--- -----------------------------Date----------------------- ---------:------------) f <br /> Septic Tank (Specify Requirements)----.---___-_-__..- <br /> J"----------------=--------------------'---._--.--------'------------------.----.------------------ -=-------------------- <br /> Disposal Field (Specify Requirements)-- --------------------�--------------------------•-------------------------------------� ---- --.------------------------'�-=�� -- -� <br /> ------------------------------- <br /> ----=------ --- ----- =-------------------------- ---- ------------------------------- .- -------------------------------------------------- - -- -------------- <br /> ( _ J <br /> {DFaw existing and required addition.on reverse side) - - <br /> hereby certify that l have prepared -this-application--and-that-the work-will-be-done-in-accordance with-Son Joaquin--County <br /> Ordinances, State Laws, and Rules.and Regulations.-of- the'San=-Joaquin Local Health District, Home owner or-icensed agents <br /> signature certifies the following: <br /> 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 />- to become subject. to..Workman's Compensation laws of California." { <br /> Signed-------------------------- - --- ----------- ----=--- -- Owner <br /> B <br /> ------Title <br /> f (If other than owner) ` <br /> FOR DEPARTMENT USE ONLY P <br /> APPLICATION ACCEPTED BY.-- .----- - DATE -- - ---•--- <br /> DIVISION OF LAND NUMBER ------------_----------- DATE <br /> --- --------------------------- <br /> oADDITIONAL COMMENTS---------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I <br /> Fina ---------=-----� -- - ------ <br /> ------------- <br /> -----------------I Inspection b <br /> A Y�---- ------------- - ---------Date.----- � -'� ,. . <br /> G 51 13 24 SAN JOAQUIN LOCAL H LTH DISTRICT es,s 21677 Rev. Ind inn <br />