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S <br /> FOR OFFICE USE: <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT v c <br /> ------ Permit-No....�0 �l <br /> ---�-------�---------------�- (Complete in Triplicate) <br /> -------------- ------------------------------ r <br /> ---------------------_-----------------.----------------- rThis Permit Expires 1 Year From Date Issued Date Issued.--- ----fid_-.7 <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 Ordi ante No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION <br /> ------------ ---CENSUS TRACT-------------------------------- <br /> V �Owner's Name.- .-.--; C�-' -- - - -------------------------------------- ------- - -Phone- --- ---- ----------------- <br /> --------- <br /> ---- zip----------------- <br /> Addressi ------------------------------- City ----------- -- ---------- <br /> - <br /> Contractor's Name-----.------ ---- --------------------------------------------------------------License #__2.7/67. -7-----Phone--- 5 -rr - - ---- " <br /> Installation will serve: Residence."7 Apartment House.D Commercial ❑ Trailer Court ❑ <br /> / -:Motel ❑ Other---------------------------------------------- , f <br /> Number of living units:------/-----Number of bed rooms..-oZ�__Gar.bage_Gr-irider--__-._-_-._-Lot',Size-------- �-��°�d� <br /> Water Supply: Public System and name------------ --------------------------------------------- ---------------------------------------- = --------Private e]` <br /> Character of soil to a depth of 3 feet: Sand >r 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-----------------------------------------------------------Liquid Depth---------------------------''� <br /> Capacity---------------------Type----------,---- ------ Material- ---------- --No. Compartments---------------- . <br /> Distance to nearest: Well-,-----•----- -----•-----------------------Foundation--------->--....------------Prop. Line------------------------.--. (A <br /> LEACHING LINE [ ] No. of Lines-.---..--_--------------------Length of each line.___---.---._.---------------Total Length.______.--..--..-------__-- <br /> 'D' Box------------Type Filter Material---- Depth Filter Material----------------------------------------------- <br /> s <br /> Distance to nearest: Wel! --"_-_- -FoundUflb-5-::--T----- Property Line------------------------------- <br /> ----- <br /> SEEPAGE PIT [ ] Depth-----------------Diameter--_-----------------Number-------------------------------ii, Rock Filled Yes E] No E] <br /> Water Table DeptF�----------------------------------------------------- Rock Size- _ _ <br /> Distance to nearest: Well-------------------------------------------Foundation------------------------ Prop. Line--------------------------_. <br /> A # <br /> REPAIR/ADDITION (Prev. Sanitation Permit __________._____:--.-.-__--;--.---_----'- <br /> Ptl (Specifyeqrr ` - �DisPosal Field (Specify Requirements) - - ----- ------ -------- <br /> �} <br /> ` <br /> --- <br /> --------- ---- ----------------------------------------- ----------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 le t to man Compensation laws of California." <br /> Signed---�`�'..~--- -----------------------Owner <br /> By---------------------------------- - `" Title -----------_,---------. --- • ------------- <br /> f other than owrle <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- -+tel - - -- ----------------------------- ------------------- --------------DATE ------------------------ <br /> DIVISION OF LAND NUMBER--- ------------------ -----------------DATE----------------------------------------------- <br /> ADDITIONALCOMMENTS------- ------------------------- ------------------------------------------ --------------------------------------------------------- ----------------------------- <br /> -------------------- <br /> ---------------------------. <br /> ------- --------------- -- ------ --- -- - ------------------------------------------------------- ------------------------- ------------------- ---------------------- --------------- <br /> Fi---------------------------------lspby: - - �,,,----------------------------------------------------------- <br /> r----- ----------- - -------------------------- ----------- --------------------- Date. ----------- ----------------------- <br /> -------------------- <br /> Final Inspection by:-_-- .-. _ l� <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.t177A-&4 <br />