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r ' <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT -� 7-%3 <br /> Permit No--- - ----- -- ------ <br /> (Complete in Triplicate) <br /> -------- ------------ ------ ---------- ---- /,�„_s:7j <br /> Date Issued.___--.-. _ <br /> --------------- "---- This Permit Expires 1 Year From Date Issued <br /> Applicahion 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 existingRulesand Regulations: <br /> -------� QQ <br /> 1 HCl{ CENSUS TRACT -------------- <br /> ---Phone -- . - <br /> JOB ADDRESS LOCATION- <br /> l 1! 7' <br /> home. _ j �: 1/ ---- <br /> Owner'sPr .IFfS - <br /> ;. <br /> ------------------------- <br /> Address------ - ------!-------------- -/1 ,Q ------- -- -------------- ----------------- City-----..._c/'</� _ Z�p�7 /£ <br /> f <br /> .C✓ (/.fJrf License #" O. Q' -1 Phone- -`------0-_ <br /> Contractor's Name.?..-------- lii� _-L`'' y /��1 ----- `.� <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-------------------------.------- ---.____.--------,------"- <br /> ' Private <br /> Water Supply: Public System and name------ ------------- -- ------------ --- --------------------------------------------- O <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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----.-----j-------Y�-------------------------- --------Liquid Depth-------------------------- <br /> � <br /> Capacity./_ ��- Type- / STMaterial Ge .!/rNoj. Compartments e, <br /> Distance to nearest: Well----- &7----------------------------Foundat�------"!_-IQ___-------Prop. Line---------------------- <br /> .- - <br /> LEACHING LINE [ ] No, of Lines------------� _____-.---- Length of each line------_t __.---._-.--Total Length _-. --------------------- <br /> 'D' Sox.----/----Type Filter Material_--/- ----_------Depth Filter Material---------- --------------------- ------------------- <br /> Distance to nearest: Well--- ---------------------Foundation----------------------------Property Line------------------------------- <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------------- --Number-------------------------------- Rock Filled Yes [-] No <br /> WaterTable Depth------------------------------------ ------------------ Rock Size------------------------------------------------ <br /> Distance to nearest: Well-----------------f-,----------------------Foundation .----------------- -- Prop. Line--------------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date---------------------------------------------) <br /> Septic Tank (Specify Requirements)------------------------ --------------------------. <br /> Disposal Field (Specify Requirements)--------- --------- -------------------- ---------------------------------------------------- ------------- ---- <br /> -----------------------------------I---------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------ --------------------------------- <br /> ---------------------------------------------------------------------------------------- --- <br /> --- ------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work wily 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 become subject to Workman's Compensation laws of California.'-- <br /> Signed---------- <br /> alifornia.'--Signed---------- --------+------ - ----------------------- ------------------- --- -------------Owner /� <br /> By------ - V U� e�'�L-------------- ft5 �F i Title--- -0 w�N��---------- ---------- <br /> ---(//�- <br /> (If other than owner) ��� <br /> FOR DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- t %----------------- --------------------------- <br /> DIVISION OF LAND NUMBER.--------'--- -- ------ - ------------DATE----- -------------- ----------------------- <br /> ADDITIONAL COMMENTS--- -------------- --- - --------------- - ------ - ------------------ -- <br /> ---------------------------------------------------------------------------------------------------- ----------------------------------------------------------- <br /> ---------- <br /> - ------------ ----------------------------------- ----------------------} <br /> Final Inspection b Date. <br /> p by:-, ---------- <br /> EH 13 24 _ SAN JOAQUIN LOCAL HEALTH DISTRICT fa s1 EV. 7/7fi 3M <br />