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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------------- ' <br /> (Complete in Triplicate) Permit <br /> Date Issued_.-__ _--?_ I <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 inance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --- C - ---- ----------------------CENSUS TRACT------ ------------ <br /> �uf <br /> Owner's Name -------- �.�1--_ Phone. <br /> --------- -- ---- -- ----------------- <br /> Address-------------- ----- Ci ---------zip----------------------------- <br /> Contractor's Name - `E cense # . . --------- Phone----------------------------- <br /> Installation will serve: Residence ❑ Apartment House Commercial Trailer Court ❑ <br /> i <br /> Motel ❑ Other.--- <br /> Number of living units:_ .________Number of bedrooms----3- _-_Garbage Grinder------------ Size___ ___.____ <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 E�_' i <br /> Hardpan p 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 seep ge pit permitted if ublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Pql' Size_�� _ .� _ -----------------Liquid Depth.___` ____---.______ <br /> Capacity-, ------Type- Material,._—_------No. Compartments__;�7-------------------------- <br /> Distance <br /> ----------------------Distance to nearest: WelL._.-------..$-'O---------------_-----------Foundation-----�/A---__.-------Prop. Line_ ____------ <br /> LEACHING LINE { No. of Lines------__,_____________.Length of each line---------to e___ __________Total Length----- ---------------- <br /> .__ <br /> 'D' Box----/-----Type Filter Material----- __-_.Depth Filter Material ________-l__J------------------------------------------ <br /> Distanceto nearest: Well-__-__�D-_ -----------Foundation------- ..............Property Line--------U __/ <br /> t - <br /> lldlc� <br /> T ,: Depth______ ____DkuP,@ter__7_L,.r Number------------/---------------- Rock Filled Yes. No__❑ <br /> Water Table Depth--------------_---41------ ----- :- Rock Size !/ ------ j <br /> Distance.to nearest: Well-------/Q�J---------------------------Foundation-----1 _.____-____.Prop. Line---------------4 ' <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_______________________;_____________-___.-_______Date__-_-___--_____________:_______--_____-__-}" <br /> SepticTank (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, I shall not employ any person in such manner as <br /> to become subject to Workman's Coin ensation laws of California." <br /> Signed-------------------------------------------- -------- --- -------- ----- ---- ------------------Owner <br /> By_` <br /> --- ------- --------Title <br /> (If other than owner) i <br /> F00qPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------�.' -- =------------------ ------------------------------------DATE.----- r ---------------------- <br /> DIVISION OF LAND NUMBER-------------------------- --------------------------------- - ------------------DATE--------------------- <br /> ADDITIONAL COMMENTS------------------ - --------------------------------------------------------------------- ----------------------------------- ------ <br /> -----•--------------------------------------------------------------------------------------------------------------------•-------------- -------------------------------------------------------------------- -- <br /> ---•-------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- <br /> -------------------------------- ---------- ----------- <br /> FinalInspection by--------------C -'-- -- - - - -------------------------------------------------------------------------------- Date <br /> EN 13 sa SAN JOAQUIN�LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M <br /> I <br />