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i <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT VO4 <br /> .................... <br /> "- "-"--" "--- -- -- ----- (Complete in Triplicate) Permit No.._................... <br /> - - - - Date Issued---.?- <br /> ................... ............. . ------------------ <br /> ssued---p----------------------------------_-."-"--"------_----- 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 <br /> /with County Ordinance No. 54499 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ./..-- I- 1oG��7/-.�7CL----.---------.----------CENSUS.TRACT............... <br /> Owner's Name.... . .. .... ... .. ..- ._...-___........._--------.....-_..---_---------...Phone._.--............--.......-..._.. <br /> .._ <br /> Address-----.-. . ................__.._.. - .- .. _ ....-:.- -City.--------- - -- ..-. ......___Zip,.-----------------_-.--_ <br /> Contractor's Name.........". -. , ...............License #-WL1.71.--Phone.`'.Y007-" <br /> Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-........... ..... ................ ... g <br /> Number of living units:. .....I-------Number of bedrooms...-S{- Garbage Grinder------------Lot Size---......'J".., <br /> Water Supply: Public System and name_ ---- -_-_-------------_-_........_ ..-... --------.-----..Private [� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK [ ] Size ... -. -L-11---------------------Liquid Depth_ ....._.-.___. <br /> Capacity./_�0Q....TYpe-.4...... .......Material--- ---------- <br /> No. Compartments--.IRI--------...- <br /> Distance to nearest: Well-....__._....._..._..-__..._........Foundation....... . . ......... .. Prop. Line_----- ..---.--.-.------ <br /> LEACHING LINE [ ) No. of Lines.....................Length of each line.....TQ----------- ---Total Length - -------..--".---"------- <br /> 'D' Box.. . .._ . T l * _ .Depth Filter Material-.....---- �/ <br /> Type Filter Material.:- _. I- ._... __---..._.-...-._Q( <br /> Distance to nearest: Well------------IL-, -------.Foundation............................Property Line----- <br /> SEEPAGE PIT [ ) Depth..__. 3fG <br /> �..Diameter.-- ' .3..1`.Number.._... .. ......--. Rock Filled Yes [ No <br /> Water Table Depth-----------------.............._........................Rock --- <br /> - --- <br /> Distance to nearest: Well-_--4---4�V.- .........----------Foundation_..... ._._ ...Prop. Line_- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------...._..................... .._---.----.-.Date--------------._ .... "____------) <br /> Septic Tank [Specify Requirements)...... __.._...............-------------------....----------- .-.--.. <br /> Disposal Field (Specify Requirements)--"--"-- ------ -------------------------- --- ------ <br /> -..........................---..............- -_..........---------_----_.-._---------------. <br /> _. ---------------- <br /> ------------ _._.................... _.-_ .......................................----....-.... ..._....-..---...... <br /> (Draw existing and required addition on reverse side) <br /> I 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, Home 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 Workman's Compensation laws of California." <br /> Signed .... ._..-_....... ........... ...... Owner <br /> _ ...... Title..- <br /> _ ------------------ -BY- -... .. ............. ..._. . - _._...... - ._ _..._. <br /> [ other than owner) <br /> OR DE RT ENT USE NLY <br /> APPLICATION ACCEPTED BY..----- ON.. -...... . DATE --------.. <br /> DIVISION OF LAND NUMBER--------------- ----------- ----- _....._.... ---- ----.._DATE -- .....-.__.._._._ - <br /> - - - <br /> ADDITIONAL <br /> COMMENTS..................... _.......- -- .. <br /> -----v-- <br /> -- - '-----.-..- <br /> . ------------ham--.w-- -d.. <br /> _ <br /> - ....... <br /> ------------------------------ - -. - _... .............. <br /> ---- ------------------------- -- - --- - ._.... ............................. <br /> - ... ... -- - - ---........_..-.__... ---. - <br /> ------------- <br /> Final Inspection by:.. ......._.Date.- FLS 3�bR LEV_ )/]d 3M <br />