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FOR OFFICE USE: FOR OFFICE USE: <br /> r APPLICATION FOR SANITATION PERMIT ��jj'' <br /> --------- ---"-_---------------------------- Permit No7,,—R <br /> (Complete in Triplicate) <br /> ---- ------------------------------ <br /> Date Issued.l�^__��?, <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 /> J <br /> JOB ADDRESS/LOCN- <br /> ------ --_..--- ..CENSUS TRACT----------- ----- <br /> ---------.Phone-------------------- <br /> Owner's NaEme ------ .:- -- l --._City f------ --- - ----------------Zi <br /> R - <br /> Address 2 -.---- ------ �._2�- honeContractor's Name--°--- --------------License <br /> Installationwill serve: Residence ❑ Apartment House❑ Commercial El Trailer Court ❑ ? <br /> t Motel ❑ Other---- <br /> Number of living units________ _______Number of. bedrooms .__Garbage Grindex------------Lot Size---- _2-S` ---- •---------------- <br /> i <br /> Water Supply: Public System and:name:-----" ---- ---- - --------------------------------- ".-- ----------------------- - _-----------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand E] Silt E] .Clay ❑ Peat EJ Sandy Loam L_] -Clay Loam ❑ , <br /> Hardpan [Adobe❑ Fill Material yes, type_______________________.._..._._ <br /> I � <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 seeps :pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC�TANK [ Size_ _.. ___ ------�_-=______,____Liquid Depth..--_v---------- <br /> f <br /> ,y� Capacity.l�i- s ,--==---Type--Material=-- '?' - No. Compartments <br /> f + <br /> 'Distance to nearest:-Well_____ ____ ' ._______- -Pro Line_ - _______-,.J <br /> l �< ------Foundation____---/_C�_l p. f <br /> LEACHING LINE [if/ No. of Lines----_._,_-___��'_____________ Length of each line, /-'' <br /> Total Length.------1 ��' ------------------ <br /> `D' Box....4---:--Type Filter Material----- Filter Material'---f_ ------------------------------- ---� <br /> Distanceto nearest: Well_.______ ___Q_----------Foundation------` E a___._!----_.Property Line---------J------______ --------7- <br /> SEE'PAG'E <br /> I <br /> SEEPAGE-PIT ( Depth----�_:� _Diameter.._____ _ � ��_-- Rock Filled Yes No ❑ y <br /> Water Table Depth-___ <br /> j--�----.Number------------ - .. (�f <br /> g 'n ---------- Rod k Size l ` �� / <br /> - f t Distance to nearest: Well.......... <br /> - �'--:------ ounatlon-_ f6._�._ wProp.�Line-.-'- 1 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------- ____..- Date__-----------r__,-------_----- <br /> _________ <br /> _--- <br /> { s <br /> ' Septic Tank (Specify Requirements)------------- -------------------------------=--------------------------- I- -----------`---." ------------------ -------` �} <br /> Dispo a Field (Specify R-equirements)---- - --------------= --------------- ----------------=----------- ------------------ <br /> --------==-------------------------`------ ------------------ <br /> ------ ----- ------------------------- -------------------- - <br /> !^i <br /> ------ ' -----; = ---- ----- ---------------------------------------- ---- `--------- --•- --- <br /> ------------ ------------------------------ - - ----------------------------..--------------------'----------------------------------------'----"--------- ----------- <br /> F (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 ensation laws of California.". <br /> Signed- ------ -------------------------------- --- - -----=--- --: -----------Owner —� <br /> Title- '*' <br /> / ------ <br /> i (If other than owner) # <br /> "FOR DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED: BY----- ,- '" DATE.. <br /> - - ---------------------- --- <br /> DIVISIONOF LAND NUMBER --------- ---------=---------------------, ---- ---------•--------= -----------------.,DATE ------- ;------------- ------------.--' <br /> ADDITIONALCOMMENTS-------------------------------- ---------------------------------•-- -- --------------------------------------------- --------- - --- ------------------------------- <br /> 4 <br /> ----------------------- ------------------------------------.-------------___._____._________________.__----____._____ - -_._____--=-___.____-________----___.______-_____.______-__-_________..__._. <br /> f <br /> ._ ---------Date Z-/- `-- <br /> Final Inspection by---------/___dZI- --- - - <br /> EH 13 24 r 5,4N JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />