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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT G <br /> ---------------- -------------------- ----------- Permit <br /> (Complete in Triplicate) � -- <br /> ------------------------------------------------------- <br /> Date Issued-07—.1--7b <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 /> JOB ADDRESS/LOCATION <br /> "— L G�f CENSUS TRACT <br /> ;.. <br /> ----------------Owner's Name � � Phone <br /> 9 <br /> zip ------------------- <br /> Address----- .. -- --------------- --------------------� Cit 1//7,00 <br /> C <br /> ontractors Name._ -------------------------&- cense #-4-3-- ------Phone_-���---------�- <br /> ---/--- <br /> ---- <br /> installation will serve: Residence Apartment House.E Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------- - ------------------------ ryry f `�rr <br /> Number of living units:----)--____---_-Number of bedrooms---3___-Garbage Grinder_-----------Lot Size----!_ f ---------------- ----D -- <br /> Water Supply: Public System and name------------------ --------------------- --------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand e 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,) a� <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 j ] No. of Lines-----------------------------Length of each+line------.-----------------------Total Length --------------------------------------- <br /> 'D' Box------------Type Filter Material--------------------Depth Filter Material-------------------------------------------------------------- <br /> r <br /> Distanc&to nearest: Well------------ ---------------Foundation-------------c-------------.Property Line-_--_____________________________. <br /> SEEPAGE PIT [ ] Depth------------- _Diameter--------------------Number--------------------------------- Rock Filled Yes ❑ No❑ <br /> WaterTable Depth------------------------------------------------------—_Rock Size--------------------------------------------- -- <br /> Distance to nearest: Well--------------------------------------------Foundation--------------------------Prop. Line------------------------_--. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---- ----------------------------- ------------ Date-----------------------.---------------------- <br /> 1 <br /> Septic Tank (Specify Requirements)---- l "`�` '5444rJ-; d•• <br /> Disposal Field (S ecify Requirements).--------------------- _____________________________ <br /> ------------ ------------------------------------------- <br /> / -------- --- ---------------- --------------------- - --- <br /> -------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------- <br /> " (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 becoubject to Workman's Compensation laws of California." <br /> `_ F .A <br /> Signed ' '---- -- ------------------------------ --- -------------Owner <br /> BY- ----------------------------------------- ---------------- - <br /> - --------- ---------------- ---------- - <br /> -Title------------ ------- --------- --- -------------------------------------- <br /> -- - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> // tt�� DATE-------------------------------- <br /> APPLICATION ACCEPTED BY--------- - - -------i✓----- ------------------- ------------------------------------ <br /> DIVISIONOF LAND NUMBER-------- --------------------------------------- -------------------------------DATE------------------ ------------------- --- <br /> ADDITIONALCOMMENTS----- --------- --------------- ------------------- ------------------------------------------------------------------ <br /> ------------------------------------------------- -------------------------------------------------------------- <br /> ------------------------------------------------- ----=------------------------------------------------------------------------------------ --- <br /> ----- --------------------------------------------------- --- - ------------------------------------------ <br /> ---------------- ------------------------------------------ ------ - - -------------- <br /> Final Inspection b -------------Date---;?L— ----�- ---------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21h77 REV. 7/7d 3M <br />