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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------- ---------- ------- 9-std <br /> (Complete in Triplicate) Permit No....................... <br /> --------------------------"---.--. .................... Date Issued._4."o.?.�d_" <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--------------- j <br /> JOB ADDRESS/LOCATION--- ­34.....­'50--- _A&Dar t,1a. — - <br /> Owner's <br /> . — - <br /> Owner's Name... _. - +" .. -. .Phone.--" - <br /> ------ <br /> Address...... � ..Ci '._. ....zi --- . <br /> Contractor's Name.------�-ELG!. A ..... . ...... . .License #.. -Phone.. <br /> Installation will serve: Residence . Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other- -- - ---- '-- •----------- <br /> Number of living units;..... ...........Number of bedrooms_. '. Garbage Grinder............Lot Size.---.. Q.....- <br /> Water Supply: Public System and name .I----------------------- -- .... ._...._..---.-..----•-- Private ❑ <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---------------------- ---- r <br /> .1 r � <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side:! W <br /> NEW INSTALLATION: (No•septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ------ ----- <br /> ----------------------------------------"---.Liquid Depth..----" I <br /> Capacity...... ... Type . •. ....---.Mate-rial-...-"-------- ---No. Compartments----- .- -------_- - { <br /> Distance to nearest: Well...... ........... ........ :.....Foundation..---..... . - . ..... Prop. Line........ <br /> - , <br /> LEACHING LINE [ ] No. of Lines ...........................Length of each line.------------ -- --.Total Length:....-..---------------- ............ <br /> 'D' Box...:........Tt ype Filter Material... __...........Depth Filter Material------- -- ------ . -------.--- --------...-- <br /> i <br /> Distance to neaFest: Well.... .......... - Foundation--------------------- Property Line....----------------------- ........ <br /> SEEPAGE PIT [ ], Depth <br /> _ isDiameter------------........Number------------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth--------------------- --•-....._._...... -------.....-.Rock Size---.......... ----._.-----. -------•------• -�-- <br /> Distance to nearest: Well--------------- -----------------Foundation.......--. ...........Prop. Line..-. --------- ....... <br /> Ii <br /> REPAIR/ADDITION {Prey. Sanitation Permit#-----------------=-- --------- ---. ...---- ---..Date-....------•-.----..-----....._I....--............. i <br /> Septic Tank [Specify Requirements)....... ---- ---- --•............... ---- - -------------------------- -------- ...... .......-- -- ............ --..... ...---- .......... <br /> Dispos I Field (Specify Requirements)._`-s.�.----- -- ['. �,, -[ �.a 1? <br /> tt— <br /> __ _ I� ------------- <br /> (brow 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 Sah'Joaquin Local Health District. Home owner or.licensed agents <br /> signature certifies the following: <br /> "I'ce ' that in the' performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> t �e _ <br /> ubj ct t 's mpensation laws of California." <br /> Sig �... _. .. . - - - - �. .... ................-------------------- ... <br /> By----------- ---------------- ------ Title .............. ...... ------------- --- I <br /> (lf other than owner) L i <br /> ti 4. <br /> FOR DEPARTMENT USE ONLY ` <br /> APPLICATION ACCEPTED BY---------- :. - -DATE <br /> DIVISION OF LAND NUMBER... .. ....... ..... --- DATE.__... <br /> ADDITIONAL COMMENTS-- -------------------- --- "_ .... ........ -.. .. <br /> ---------- -------------• .............--- - <br /> t f <br /> .................... ...................... ......... ....:.... _ <br /> �.:. , <br /> y:....-.--- �--.- - 2� <br /> .. -------- - <br /> ------------------ ----- ------- _ <br /> Final Inspection 6 ..Date ..... . <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 21677 REV. 7/76 3M <br />