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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------- <br /> (Complete in Triplicate) Permit No. <br /> -------------- ---- -- - - ------------ <br /> � 040 - Date Issued___"-b^- <br /> .-•-------�--------------------------------------- This Permit Expires l Year From Date Issued <br /> Application is hereby made to the San Joaquin_Local Health District forma hermit to construct and install the work herein described. <br /> This application is made in compliance with County O inance No. X49 and existing <br /> Rules'and'Regulations- <br /> � <br /> JOB ADDRESS/LOCATI I34 3> -- --------- J----------- -------------- •------ ---CENSUS TRA <br /> CT------------------------- ----- <br /> . . <br /> Owner's Name-------- -- - -- -_-- - <br /> -- --- -------- ------- - ------ ---- ----------Phone-------- ----------------------------- <br /> -Zi cI Jr� <br /> Address-..--------- City p <br /> Contractor's Name__-- •a...- --f - -----License #_ zIZZ�_._-Phone------------------- <br /> Installation will serve: Residence ❑ Apartment House Commercial ❑ Tr iter Court ❑ <br /> Motel ❑ Other--iv, <br /> Number of living units:__._._/49------Number of bedrooms-------- ---Garbage Grinder------------Lot Size------------------ -------------------------- -------------- <br /> Water Supply: Public System and name--------------------------------------------------------------------------------------- ------------------------------------Private [ <br /> Character of soil to a depth of 3 feet: Sand F) Silt F1 Clay El Peat ❑ Sandy Loam ZClay 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 /> f <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth---------------------------`,] <br /> Capacity---------------------Type -- - -----------------Material--------------------------No. Compartments---------------=-----------------�` <br /> Distance to nearest: Well------------------------------- ------Foundation.-------------------------Prop. Line-------------------------- <br /> LEACHING LINE [ ] No. of Lines-----------------------------Length of each line-----------------------------__Total Length --.-----_------------------------------ <br /> 'D' Box------------Type Filter Material-_---- Depth-Filter Material-------------------------------------------------------------- <br /> Distance to nearest: Well_--------------------------Foundation.---.----.--.---------______Property Line----------------------------------- <br /> SEEPAGE <br /> _-__ .--.------------.-----.SEEPAGE PIT [ ] Depth__.-__ _v_D1amEter_-------------------Number--------------------,----------- Rock Filled Yes ❑ No❑ <br /> WaterTable Depth------------- --------------------=------------------------Rock Size-------------------- `-=----------------------- <br /> r - undation'---- <br /> ----------.--.--------Prop. <br /> Line---------------------------- <br /> Distance <br /> ine.-------------' <br /> -------------.Distance ta.nearest: Well- %----------------- o <br /> REPAIR/ADDITION {Prev.Sa�n � <br /> itaton­T�ermit --------- <br /> - Date ----- <br /> Septic <br /> Tank (Specify Requirements) <br /> --------- - --------------- <br /> r <br /> j <br /> ' - 1 - -- . - <br /> --_ <br /> DisposaFied ------------ <br /> . 6 - -- - - __. <br /> ---------------------------- ------------ - --- ----------------------------- ------ ---------- ------------------ <br /> w, {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 Com nsation lawsA California." <br /> Signed-------- ------------------------- - --- --- -------- --- --- -- -------- --Owners <br /> By------------------- ----------------------------- = - -- -- - --------- -- Title <br /> 4 <br /> (If other than owner) t <br /> FOR DEPARTMENT USE ONLY <br /> ------------------ _r_.. <br /> APPLICATION ACCEPTED BY........C_--- --- - - ..- DATE.---- -------------------------- <br /> DIVISIONOF LAND NUMBER--------------- --- ---- ---------------------------- -- ------ ------------------ ----------DATE ----------------------------------------------- <br /> ADDITIONALCOMMENTS-------------------------------- ----------------------------------------------------------- ---------------------------------------- ------------------------- <br /> -------------------------------- ---------------------- ------------- -------------------------------------------------------- ------------------------------------------------------�' -------------------------- <br /> Final Inspection by:--------C -------------------- ------------------------------------------------ -------Date--- -- ���-------------'-` <br /> EH 13 24 SAN JOAQUIN LOCAL`HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br /> � r � <br />