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FFOR OFFICE USE: <br /> OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- ----------- ----------------- ---- Permit No..---��_��� <br /> (Complete in Triplicate) <br /> --------------------------------------------------------- <br /> Date Issued___________________ <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 /> ------- ------CENSUS TRACT---------------------- <br /> JOB ADDRESS/LOCATION.__._ �7 --- - -- pG <br /> Owner's Names --- -----------Q---�------- Phone_ <br /> Address------------' --- _ �- I�Ali----.-.Ci Zip ------- ------------- <br /> �Y Q <br /> Contractor's Name ' ------------------ ----__License # Phone__ Llf�p....94 9:?7 <br /> Installation will serve: Residence�< Apartment House.E] Commerciol .❑' Trailer Court El <br /> Motel F1 - - <br /> Other---- --------------- --- -- --- - -- gam' <br /> Number of living units:,., ____.-_'__Number of.bed room s:____ ___Garbage Grinder------------ Size..... IMCt �� -- ----- --- -- <br /> WaterSupply: PubIk,Systefn7and name------------------------- ----------------------------------------------- --,:-_--------------------------.-. -----------------------Private <br /> Character of soil to'6of'1feet: :Sgnd;[1¢ Silt❑ Clay ❑.e, Peat ❑ Sandy Loam ❑ Clay Loam <br /> Hard pa z_ Adobe❑ FiII'MdteridI y_._.._If yes, type-----------------._.____.__- <br /> [Plot plan, showing size of lot, location of.system in relation to wells, buildings, etc. must be-placed ori reverse side.] �. <br /> NEW INSTALLATION: (No, septic tank or seepage pit permitted Ii public sewer is available within 200 feet,) r► <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [,] "r ,_______________----_-----------------------------Liquid Depth -------------- <br /> Capacity T e-------------------- Material �' ---------- -No. Compartments -------- ------------------- <br /> Distance to.nearest: Well--------------------- ----- -------Foundation.._---.----•---------------Prop. Line.-------------------------- <br /> i <br /> LEACHING LINE [ ] No. of Lines______________________._____..Length of each line - -------------------Total Length---------------------------------------E-_ <br /> ] 'D' Box------- ----Type Filter Material---------.#_ ___!_.Depth Filter Material------------------------- - -----------------------------------. <br /> Distance to nearest: Well----------------- -- Foundation---------------- ­,_-,Property Line------------------ ---------------- <br /> SEEPAGE <br /> _--.-_.--_-SEEPAGE PIT j ] Depth________--------Diameter---------------------Number-------------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth--- ---------------------------------- -------------------Rock Size..----.---------- ----- ------------`_ . <br /> Distance to nearest. Well..-----------------------------------------Foundation----------------- -----.Prop. Line__'-:-`-`- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-- ____._ ��- <br /> Septic Tank (Specify Requirements)----- ` r� ------------ - ------------ <br /> Date - <br /> ---------- <br /> Disposal Field (Specify Requirements).---- -- --.--7.-3.--- r --------------- <br /> -------------------------------- <br /> --- <br /> - S <br /> --------------------------------------------- ----------------------------y-------------- - ----------------- :: <br /> --------------------------------------------- --- -----=------------------ ---------- <br /> r --------------------------- <br /> ------------------ <br /> {Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application ani ah t'fh o k wili`be done inaccordance 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 Compensation.Jaw-s.,.,ofCalifornia," _— <br /> Signe �.. �S f _.__ .: ti �. .; ------------------- -OWner .� l <br /> ------- - <br /> f <br /> Title h <br /> (If other than owner]' Y <br /> ° FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - ----------- -----'---- -- DATE Z <br /> DIVISION OF LAND NUMBER --------------- DATI <br /> - --- <br /> ADDITIONAL COMMENTS.--------- -'---------------------- ------------------------------------- ..---------------------- ----- - -------------------- ------------LS----`-K <br /> =----------- -- --------- ---------------- -------------- ----- -------------------------------------------------"----.------------------------------------------------ ------------------------------------ <br /> c <br /> ---------------------------- ---------------------------------------------------------------- - - --- ------------------------------------•------- -------------------------------------- --- <br /> ----=------------------- <br /> -----fig_�e.... _ <br /> Final Inspection by -..._ /_ ----Date.------ a_.--- <br /> EH 13 24 SAN JOAQUIN LOCAL HEAL DISTRICT F&S 21677 REV 311A <br />