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r <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .--- --- � .. ,�).d r <br /> © ---_r�..._ __��- --��-------- {Complete in Triplicate) Permit No. ... ... . .. ..... <br /> -------------------- <br /> �a- .. _. 2/'F <br /> This Permit Expires 1 Year From Date Issued 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 comp 'a ce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO Y // "_-..-. --.-.. ......CENSUS TRACT..............._-_ -- .... <br /> •-------------- <br /> Owner's Name . - -- - <br /> - -- -..-. -SJ9L/z90/r� .....Phone <br /> ,rryc�..�. /� _.. . ------ ------------ �=A .2 <br /> Address Q --- pt-+ 'vC-... .City = --_----- <br /> Contractor's Name------------ -- .. ! ......................License # _ .....Phone- <br /> Installation will serve: Residence-K-, Apartment;House (] . Commercial ❑ Trailer-Court ❑ <br /> Motel ❑ Other............ -----_--------------------- <br /> Number <br /> .. . ----------- ---- <br /> Number of living units:---.............Number of bedrooms..-77<Garbage Grinder.....-.-.---Lot Size------ ._a..- Z . <br /> ~` -_----Private <br /> Water Supply: Public System and name------- ------------- ---- - - -- ��---• • -....--- ------------------- -�----- -- -------: ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat}C] 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 TREATMENTSEPTIC TANK " <br /> [ � [ 1 Size---==-------- - --- ------------------------ Liquid Depth------------------ -. ..--- <br /> i <br /> Capacity_........ ........ Type.............-------:..Material"---- ` ----------------�No. Compartments-- --_......._-- -- <br /> Distance to nearest: Well--:----------......_............ .........Foundation-. :4-............Prop. Line-.----------._.--.-----. <br /> LEAC#fING LINE [ j No, of Lines ................... Length of each line.._-_._._-._-..._-._.__-. .._`Total Length .............. <br /> ------------- <br /> 'D' Box---- .--...Type Filter Material........ --. .....Depth Filter Material................... ....-------.........----------- --.._.... <br /> Distance to nearest:.Well.........................:..Foundation----------------------------Property Line--------------------.-...-------... <br /> SEEPAGE PIT { } Depth................Diameter............-----.- Number-------------------------------- Rock Filled Yes ❑ No <br /> Water -Table Depth------------------------------- ----------...............Rock Size----------------------------------------•------- <br /> Y Distance to nearest; Well------------- Foundation................-. ..-..Prop. Line.._..-_- „..,.� <br />[ REPAIR/ADDITION f Prev. Sanitation Permit#-------------------------- ....... ...............Date....._-........................ <br /> .___...--_--} <br /> Septic Tank (SpecifyRequirements).-- <br /> - --­------------- ----- -------------- <br /> - �`. +F � <br /> f -- ..-.... <br /> Disposal Field [Specify Requirements).......G✓�x ...__ r '-- -- ---- - <br /> K. <br /> -- - <br /> - <br /> . <br /> (Draw existing and required addition on reverse side) <br /> `I heieby 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 ,jRules 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 Compensation laws of California." <br /> Signed Owner <br /> By...... ----- --- ------------ --- Title `. <br /> (If othe' than owner) <br /> OR f`PAR <br /> TME T ONLY <br /> IF <br /> APPLICATION ACCEPTED BY---------- -- -. !`"- ---- --------- ......DATE 3. . .....'. ............ <br /> DIVISION OF LAND NUMBER ....... ..... .......... ........ ... : -------- - -------------------_-DATE._..-------............. ------ <br /> ADDITIONAL COMMENTS- ------------ ------------ - ------_ <br /> -----------........................ ------ .............. ---- ---- . -- .----- -- ------....._._....------------. .....--... -- <br /> ------------------ ------------ <br /> Final Inspection b Dat - -� ... <br /> y:....... .... <br /> F3S 21677 REV. 7176 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 <br />