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FOR OFFICE USE: <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -----•--- Permit No. <br /> (Complete in Triplicate) <br /> Date Issued...------:•-----..-- <br /> :--•-•• •-••........... .. .......................... This Permit Expires 1 Year From Date Issued <br /> 6. 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 ADD <br /> RESS/LOCATION..rI/..3.�: - .....:, L f CE SUS TRACTf --.......--- <br /> ----------- <br /> Owner's Name.... -�-- doe <br /> EMi -41--i--- "�"�-r'-C�i.� -.-..�-.... -°--':4....�.. .-.3- -T.i^�.t-�y'. --l�l"�/. Phone...--�--��---•--:------�.............. <br /> _ p <br /> s Address------- �.� ... ,L:J �l� }.JrSG:�Il ... -� 11�G.�....--- ..... City r r-cw_0+1.... CIA_ -...Zi ����.0......... <br /> jMl r p g`-� <br /> Contractor's Name--y F:� -R.�> i I. ..... . License #3 .Q1 9'].._Phone.. �.- .7. <br /> p i <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [E- <br /> Motel ❑ Other-- -.--....------ .- -- --.------------------ <br /> Number of living units:.........r------Number of bedrooms............Garbage Grinder------------Lot Size......... ....................................... .......... -- <br /> Water Supply: Public System-and name---- - ---------- ------------------- ---------------- ------ ------- --------•------.Private <br /> !` Cha`racter of soil to a depth of 3 feet: i Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ <br /> F <br /> Hardpan p ❑ Adobe if"' Fill Material.., -- If yes, type....-...................... <br /> ...... <br /> (Plot plan,showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.[ <br /> s NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK -------Liquid Depth......................_... <br /> E ] Size....._.... - ••--•- • - - ----��------�------ <br /> Capacity................ .... ..Type................. ....-Material-- ----- No. Compartments ------ <br /> F r Distance to nearest: Well. ............ . ... Foundation------. .... .............Prop. Line.................----------- <br /> LE CHING <br /> ------- <br /> LEACHING LINE [ ] No. of Lines ------------------------- Length of each line--------------------------_-- Total Length -- ------------------------------ <br /> k � 'D' Box....- -.-I-Type Filter Material................... Depth Filter Material.-------.------------._.-..----------------------............... <br /> Distance to nearest: Well-----_-.:...................Foundation------------------- --------Property Line--------------------- ------- <br /> SEEPAGE PITjf <br /> [�/� Depth.add..-..-.Diameter.... .�.......Number------- ------------------- Rock Filled Yes 21 No ❑ <br /> Water Table Depth---- <br /> . ....... RockSize l-%... - <br /> - <br /> # ;Of <br />' Distance to nearest: Well------..�0.___..___ .Fou ndation,-... � <br /> --40 ._....Prop. Line....�� ........ <br /> REPAIR/ADDITION {Prev. Sanitation Permit#------------ .................... ...............Date.............................. [ <br /> SepticTank {Specify Requirements).........................___-------- - .......... ....---------........---=---------------------- -- ----- -- . ---..... <br /> Dislpasal Field {specify Requireme +rA �...... S'u1- <br /> F <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 /> i Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> f siginature 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 becomes b'ect toWorkman's Compensation taws of California." <br /> Signed..------- �J'��p.- --.--Owner <br /> , <br /> BY............................ --- ---_ Title----- .__--------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br />' �:r• <br /> AR4PLICATIONACCEPTED BY. -- ..... ------------------------------------------- --- ----- -------------------------- - -DATE ........... -------------------- --------- <br /> DIVISION OF LAND NUMBER-------------- ----------------------------------------- ......................................DATE..---- ----- --- <br /> d- <br /> ADDITIONAL COMMENTS.....----------- ------------------------------- ---------- <br /> IM� --------- --- -----------------. ------------ -------------- ----­-------­------- --.._..------- --------------- ---- - - .-........... <br /> ------•---•-------------------------- . <br /> I� I---- --- ------------ •-----•-------------------------------------- ----------..----.--- <br /> -•----- ------------------------------------ --------- --------------..... ---------.-------------- ---- ..--------- ..--- .--- . ...... <br /> Final Inspecflon by:. .......... - ----Date....................=---_ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76.3M <br />