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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ` (Complete in Triplicate) Permit No.:..,.._.............. <br /> •--------------------------- ---- - ------------- <br /> y <br /> ....... ..................... ------.. .. This Permit Expires 1 Year From Date Issued 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 /> JOB ADDRESS/LOCATION._..-C o ...141ai-Y 9.9...-- �.T� --------- ..............CENSUS TRACT,_............................ <br /> Owner's Name.... IJ1.G.K..... Oe%Ndr1.L.. !. -............: Phone..31�8.-.. .7.�1. _.. <br /> ..............-. . ---._............. --.... --- <br /> Address /..,X' 9i.......... . ------ ------------------- -----city--------k'e.D.1......................'-i­zip----------------- --....-- <br /> Contractor's Name - �•..Q....:��R�/.SeG�.._�_.40 .-..........License #.. .5.. 3. .... .Phone.-.6444-n, 60.7------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Y Motel X Other_... .......... ....... . . <br /> Number of living units: ---------------Number of bedrooms.--.-.-. ...Garbage Grinder------------Lot Size................ ------------------.__... ..._ .. <br /> Water Supply: Public System and name_ ............__. ----• ----------------- --.-----------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑. Clay ❑ . Peat ❑ Sandy Loam X 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 TANKSize ....... .. . .... ...... <br /> --- ------ ---------------------Liquid Depth.-.-....................._Q <br /> . . . <br /> Ca acit -—Type------------ --...Material--------------------------No. Compartments-....... <br /> Distance to nearest: Well.---------- .......... .. .. .........Foundation-------- ..Prop. Line........-.-- - ---------_- <br /> LEACHING LINENa. of Lines ,'............. .............Length of each lin8------------------------------Total Length .. ........-..-----. .---- --------.-- <br /> [ 1 <br /> 'D' Box- -.........Type Filter Material........ ..... .... Depth Filter Material---................ .....-.............. - - -- ---- =....-.-. <br /> Distance to nearest: Well-----------... ............Foundation----_-.---..-------....- Property Line...--------.-----.---------....per <br /> SEEPAGE PIT [ ) Depth-- ...... .....Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth-------------------------_--. ---....._................Rock Size---------- -----------------------•- - -------- <br /> Distance to nearest: Well----------------------------------- - --Foundation---.....----------------..Prop. Line......-...--------...._..-- <br /> REPAIR/ADDITION (Prev, Sanitation Permit#----------------------------------- ...............Date_.........-.. ...............___--------) <br /> Septic Tank (Specify Requirements)_.. .... ........... .. .........._..........------- <br /> Disposal Field (Specify Requirements....- '18,y>l_ S --. BILA/w/- Pies-------- ----------------- .............. <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 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 <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 s b)ect Work an's Co pensation laws of California." <br /> Signed.... - - ----- - --------- ------Owner <br /> By..----- -- --- Title. • -------- --- <br /> --- <br /> ------------------------------ -- - <br /> (If other than owner) <br /> ,,,FOR)DEPARTVEPAT USE O LY . <br /> APPLICATION ACCEPTED BY---------- .. . .........DATE ...... ..- . ... .� - - <br /> DIVISION OF LAND NUMBER...... ..... .... .--- - --- - _......-...DATE....--,:. <br /> ADDITIONAL COMMENTS......... ..... ----- .... .. . ........ <br /> ---------- -- <br /> -•-------------- --------- --- <br /> -- ------ <br /> ------------------------------------------- . . ----------------- -- --------------------- <br /> Final Inspection by:.----- - moi[. .................................... Date. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT MS 21677 REV. 7176 3M <br />