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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------- �_ � <br /> • (Complete in Triplicate) Permit No. �_ <br /> ---------------------------------- <br /> ------ Date w Date Issued--.- <br /> ------------------ ------.- -__ This Permit Expires 1 Year From Date Issued f <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 /> T <br /> JOB ADDRESS/LO ION. :,rJ � jj -- E--- .7 F /Q P ---------------------------------CENSUS TRACT` ----- - <br /> Owner'J Name. 4 lb -------------- - ----------- Phone-7T- ---------------------------- <br /> y <br /> ! o <br /> Address �f`---�----+-.- .... <br /> -- /tom' ° LAM <br /> .. CitZip -` <br /> Contrac is Name--- -----------------------License #----3__r7 t---Phone_--341)___- -- I <br /> Installation will serve: Residence ❑ Apartment Hous C m rcial F-1TrailerCourt ❑ ' <br /> l 1 Motel ❑ Other---- -- x +�._____. <br /> � f <br /> Number of living units:-____f..-____Number of bedrooms_... ___Garbage Grindea_.__.__.____Lo# Size_:_,._. - ,-------------------- ---- <br /> � t <br /> Water Supply: Public System and 'name-------------------------------------------------------- -- ----------------------------- --------------_--.------------------------Private <br /> Character of soil to a depth of 3 feet: _ Sand ❑ Silt ❑ Clay ❑ Peat n Sandy Loam ❑ Clay Loam ®-" <br /> Hardpan ❑ Adobe ❑' Fill Material-..--'------If'yes, type---"------------=-------------- ' <br /> z i _: <br /> (Plot pian, 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--- 'X�j_ _____ ___�d ------------------Liquid Depth.._,.,-- --___--.---- <br /> 1 nn W <br /> Capacity �.Z ---Type----- Material-- [_ Q4-.,--------No, Compartments-- -�------------------------ <br /> r r ' <br /> Distance to nearest: WeIL__________ ___ _ _____` Foundation.__lD---.------._.__.Prop. Line__-.--------_--._-----. <br /> LEACHING LINE [c.]— No,. t nes.____.._z- Length of each lino_,__ ��_____________:._._.Total Length.--.± ------_.--,_----_---_-_--.- <br /> rD' Box------------Type Filter Material/,rZ� 4 bepth Filter Material.__.2-----_____-------------------------------------------- <br /> an <br /> Distce to nearest: Well -----------Foundation -_--- Property ef'�---------- <br /> � ] �� �---.___--Foundation----�'�-�- ___---.Proert Lin -. -------------- ---- <br /> SEEPAGE PIT 4:_)• Depth._ ..=__.Diameter ___.Number--------------_`�- ------------ Rock Filled Yes No <br /> Eli <br /> Water Table/DePth._ __ -__-_ ------------------------------------ <br /> -------------- ---- Rock Size___ -��-r---r---x�--�--/-- '--------------- <br /> Distance td�qeaest, Well- .- .. --------------------Foundation----- -------------Prop. �P <br /> � <br /> Line--------------------------- <br /> REO kDDITION <br /> ---------------------___-REPAIR/ADDITION (PyyrY(w. Sar itb tion Permit#----------------------------------------------------Date-.-------------------------------------------- <br /> } <br /> SeptTank (Specify Req­ireMe ts)-----------------=-------------- ------------ ------------------------- ----------------- ---------------------------------- --------- <br /> 6isposall Field (Specify Requirements)----------- - ---- - --- ------------=--------- -------=------------------------------------------------ ------------------------- <br /> ( <br /> -- <br /> f w. <br /> --- -------- - - <br /> . •;, {Draw existing and required addition on reverse side] <br /> I he eby,: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 performanceAf the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject t Workm s Compensation laws of California." <br /> rk ]- <br /> Signed--i- =--- ------ ---' Owner <br /> -------------------- -- <br /> ------------------------- f] <br /> ----------- <br /> By-1 --------------t =----------_-- ... = = Title-_( /UK_," ------- ------- <br /> (If <br /> - / <br /> 1 <br /> ( an _owner] I <br /> Y j [FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED, 8Y__-___ ��. ___ _�_ _ _ • _ ._ <br /> --------------------=------ ----------DATE.--- �-=�-- -- <br /> Y DATE . <br /> DIVISION OF LAND NUMBER :-:..-------------- ----------------------------- <br /> ADDlTIC11VALCOMMENTS - ------------------ --------------------.-------------------------------------------------- =----------------------- ----------- ---------- ---- <br /> ------ ------------------------ ------------------------ <br /> i <br /> 1 <br /> �f � � -- �---------- �- --------------------- ---------------- -- <br /> Fos 21677 Rev <br /> . �i�b 3M------------------------------------------ <br /> Final Ins ecton b �- ----------._Date------- ------ <br /> Eli <br /> - <br /> EH 13 24 SANJOA IN LOCAL HEALTH DISTRICT <br />