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'FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- -- =; ---------------------------------- <br /> (Complete in Triplicate) Permitr - <br /> ----------------I---------------------------------------- <br /> Date Issued_.___7=,22"_7J1"_ <br /> --------- ----------- ----------------------------------- This Permit Expires 1 Year From Date Issued <br /> r <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 FigG ---------I----------------------- r-.CENSUS TRACT ---------------------- <br /> Owner's Name- Phone- <br /> Address------ <br /> hone-Address------ --- <br /> Contractor's <br /> -Contractor's Name------ - _-- ir__. ,tlG'_ ----------------------------------------License # �i- ------Phone ---- _- <br /> Installation will serve: Residence❑ Apartment House Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other___' 1 �i2,.___.____._ <br /> ---- <br /> Number of living units:----- ----------Number of bedrooms._CZ----Garbage Grinder------------Lot,Size-------6_`7..... --_________________________ <br /> Water Supply: Public System and name------_-----------_----------- r _____ Private <br /> --- ----------=----------------------------- <br /> Character of soil to a depth of 3 feet: Sand ❑ 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 /> PACKAGE TREATMENT I[(No SEPTIC.TANK. seepage It"�, 5i Bitted ipublic is available within 200 feet,} %X,A <br /> septicf p. p p '! Q <br /> f <br /> ----------Liquid Depth.5-.---------------- <br /> Capacity-/-. _ ------Type "_c _ r_Matei ial--------------------------No. Compartments--�--->-------------------- <br /> Distance to nearest: Well_- - p__--------------------- Foundation.__-__.____________.Prop. Line.___ r.�Q_.____._____._. . <br /> LEACHING LINE [ ] No. of Lines--_ ' .-----._ '__-yLength of each line-__-1�2!_r�___.____-Total Length------ ?___ $ .__ <br /> r ... <br /> D' Box---l-------Type Filter Nlaterial_4 _x� pth Filter Material_------1 -----------,-------------------------------------- <br /> Distance <br /> ____ -_________._.Distance to nearest: W�,I,I___ _ on__ Property L'ine;._�------------------------ <br /> a <br /> [ ] Depth �-'_Dia+xlete`______t _- ,NumbeUndatil T <br /> SEEPAGE PIT p ______________________ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth <br /> - - _ <br /> .Rock Size------------------------------------------------ <br /> Distance to nearesf`Well'-�t` ------------- <br /> ---------------------Foundation-------------------------.Prop. Line.--------------------- <br /> r, <br /> REPAIR/ADDITION {PrevaSanitation Permit# _ _ _ <br /> '" �" _____ ___________________________-Date__..____ ____. ______._____..___.__._ _ <br /> y i [ <br /> Septic Tank {Specify Requirements) =---- ------------------------------------------- ------------------- - ---- -------------------------------- ---- - -- ----- <br /> Disposal Field (Specify Requirements)---------------------- --- ---- - '__________._________ <br /> ---------------------------------------------------------------------------------- <br /> I ! itr <br /> --------------------------------- ------------------ --------l°--------------- ---------------- --------------------------------------------------------------------------------------------- <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 f <br /> signature certifies the following: I r <br /> "1 certify that in the pe ormance.o"Ke work for which'this-permit is-issued,.f`'shall not employ any•person in such manner as <br /> to become bject o an's<C nip�nsation laws of California." <br /> Signe --------------- ------------Owner <br /> By-------- ----------------- ----------------Title - --- ---- ---- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- -------------- -------------DATE . = '' --------- <br /> DIVISION OF LAND NUMBER ------ -- - .--.DATE------------------------------------------------ <br /> ADDITIONALCOMMENTS--------- ------------•------------------------------------------------------- I----------------------------- ------------------ ---- -- <br /> -•----------------------I------ --- -•-=-------- ---------------. . ------- -------•------------------------------- ------- ----------- ------------ <br /> - ----------------- -------------------•----------------------------------------- -- <br /> --------- ------------- <br /> ------------------------------------ ------ ------ ----------------------- --------------------------------------------------------------------------- - -- <br /> - - ------- - - <br /> Final Inspection b Date.-___ ----------- <br /> ----.__ <br /> ----------------------------------------------------- ---- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&S 21677 REV. 7176 <br />