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,e FOR OFFICE USE: FOR OFFICE USE:; - `% <br /> APPLICATION FOR SANITATION PERMIT <br /> ................. <br /> (Complete in Triplicate) Permit No..7 <br /> ------------------------------------------------ Date issued-.�y�7-�� ( <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 /> --•--- -�---.-.,CENSUPShTRACT. <br /> JOB .JOB ADDRESS/LOCATION.....� .. <br /> .........=Owner's Name - . ----- ................. ............... ------------ ...Zip_ GtAddress----...... <br /> :r <br /> - <br /> Contractor's Name.-t..-- -- -� ------- - -- License #-�-- ------ -�--.-....----..Phone-- -------------..------ s <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------- -------=----------_------ •- - <br /> Number of living units:..-t.--------Number of bedrooms-....Garbage Grinder---.-.- -Lot Size.--..... 5. G`` <br /> Water Supply: Public System and name,. ............... ........ .......... -------------- .............. ------- ------.Private ❑ <br /> Character of soil to a depth of 3 feet: SandQ It[-] Clay F] Peat ❑ Sandy Loam E] Clay Loam El <br /> Hardpan F1 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.) N <br /> NEW INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is avoilable.wifhin 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ..........-............------------------------------------Liquid Depth.-------.---... <br /> s # <br /> � Capacity...........--- ------Type............... - Material-- --------- -----------Na. Compartments ---------------------- -- ----- <br /> Distance to nearest: Well...........................................Foundation.......... - Prop, Line........-..........--------. <br /> LEACHING LINE [ ]r No. of Lines ................-----........Length of each line....._------------------ --Total Length . ------------------.---------------- <br /> ;v`D' Boxy , Type Filter Material........ ...........Depth Filter Material...........-....... ._...... . ---------.------...... <br /> . . Distan 5+to nearest: Well----------------_-------_.Foundation.......---------------------Property Line-------------....................... <br /> . <br /> V SEEPAGE PIT [ ] Depth. .-�.-.......Diameter--------------------Number------------. -------. ----- Rock Filled Yes E] No i <br /> Watertable Depth----------------- ........---------- --• -- --....-.Rock Size- ............-------------------------- <br /> Distance <br /> ----------- .-------Distance to nearest: Well-------------------- - ...... ...p,_.--,Foundation... ...........Prop. Line---- . ............. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-_---------- -------------- -------- ------Pate.............---.-------.--.-.-----------------) <br /> Septic Tank (SpecifyRequi�emer% E .-=. ..._T - - ----- -------- ------ --- ---------------------:-------------------.-- ....------.. ------- ............. <br /> Disposal-,Field (Specify Requirements) e. .r�a" / 'G" , <br /> tea <br /> 1 _5; <br /> i <br /> Q. ... -- <br /> (Draw existing and required addition an reverse side) <br /> I hereby certify that l have prepared.this application and tl at'the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, acid Rules and. Regulations_of._irhe 5a_n Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: - <br /> "I certify that inr the performarice of the work for which-this permit is issued, I shall not employ any person in such manner as <br /> to beco a sub]ect. to"Workman's ompensation laws of California." <br /> Signed.l��. --- ---- ._._.Owner . <br /> Title ---------------------------- ---------------- ...... <br /> (If other than owner) r <br /> FOR DEPARTMENT USE <br /> APPLICATION ACCEPTED BY.--._ <br /> l .VA.. ti..- - DATE .._. �,2 7. ... ......... <br /> DIVISION OF LAND NUMBER... ...... .................. ............DATE----- ------------ .......... ---------- <br /> ADDITIONAL COMMENTS....... ........_.. . ----- ... <br /> --------=-------•----------......--- --------- - ---------- ---...----........-. <br /> t ------- -- ...... -- <br /> --------------------------------- = <br /> Final•Inspe6on by:-- ------•. -- -- <br /> Date.- <br /> SAN <br /> EH is sa SAN J AQUIN LOCAL HEALTH DISTRICT F�sg ;Rev. r/76 3M <br />