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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------- --------------------------------- rI <br /> : <br /> (Complete in Triplicate) Permit No--. <br /> is f Date <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: 3 <br /> JOB ADDRESS/LOC ION.,1 . 'G� ------------lv` __CENSUS TRACT - <br /> 1 ` <br /> Owner's Name--- -- " e <br /> <. .. : - " - -.---- -- ------ -- --------------' ------ ---' - ----- -------- ----- <br /> Address---------- ---- �1------------------ - " Ph` ?- <br /> :. City : Zip T_5.r�-- 77- <br /> . J <br /> Contractor's Name-_ --- -- ---- ----- �F License #. ------2Phone <br /> ---------=--- <br /> t 4». <br /> Installation will served F Residence [ Apartment House ❑ Commercial ❑ kTrailer Court.0 <br /> 3 <br /> :,.Motel ❑ €Other---- y. 4c'_..3r - <br /> Number of living units:__ <br /> m . r ms _ . ot5;Size_ __ -- .__--_._- ."t; ""-""."-" --------�- <br /> --- <br /> Water Supply: Public System}arrd.name `:_---- -------- - ----- i- ------ "- Private [Y <br /> - <br /> Character of soil to a depth_of_3'feet: ; Scind E] :Silt E] 'Clay E] Peat E] Sandy Loam_ ..,b,.,�Clay Loam ❑ w <br /> ` Hardpan E] Adobe Li Fill Material-.." ._. If yes, typ�._e_..-'-'I----------------------------- <br /> ----___. <br /> (Plot plan, showing size of-lot, locafiori'of-sy}stem in relation-to-wells, buildings,'etc. must be placed on reverse side.),,- <br /> NEW INSTALLATION: (No septic:tank'br?seepage pit permitted if public ewer is a a labl within 200 feet,)T. <br /> PACKAGE TREATMENTZI I'.. SEPTIC TANK �I I Sizie---- =-- :--- -------------------------- - - -- Liquid Depth = � <br /> r nearest: Well �---Material___.___._�_-----------t-----No. Compartments__"__�__-._____"_-"________________ <br /> Distance to� <br /> c r <br /> � e . ---'---- -Foundation 7-7--4i.--------Prop Line_ <br /> LEACHING LINE [ I No. of Lines. ----------------------------_Length.of each line• -- -. ;.._ Total Length.__ ------- , <br /> D' Box <br /> ato•ne�eType Filter Material- --- .Depth Filter Material_-------------------.____,-____ --------____".--""_-_____". <br /> Depth--- --- ---_ -D Diameter ----- ----Numbeundation--------- -'------'------- Property Lirie_-'`-'------------------ <br /> SEEPAGE <br /> ::--'---- -- • - -'--- <br /> SEEPAGE PIT .. ' <br /> a <br /> =-------------- ` Fil e ❑ N <br /> � T: Y <br /> i Water Table Depth-_ti- " ` Rock Size '` s °'❑ <br /> - <br /> ., <br /> REPAIR ADDITION` Prev. Sanitation Permit-#-________________",�.-"_--" -_" -"--------;Foundation._,_____,__---�_.___-__.Prop, Line___-__"______._"_-_.______. �l <br /> Distan'ce to nearest: Well------ - <br /> _r-m : J / <br /> �� __" <br /> / I D ------------ <br /> y — -------------�"-ate , <br /> Septic Tank [Specify Requirementsa,l'Z- ----- ---------------- ----------- <br /> -i ��gg- <br /> Disposal Field (Specify{requirements! � d..___ ,ter _ -. --_ -------------- <br /> -----I...... <br /> ------ <br /> ------------------------------------------------------------------------------------------------------------------------ <br /> t <br /> (Draw'existin and'required addition'on reverse side) -r <br /> I hereby certify that.l 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: i <br /> "I certify that in the performance'of.the work for which this permit is issued, .1 shall not employ any person in such manner as <br /> to become subject to Workman's Co nsation; I of California." <br /> Signed---------------------------- = ------ Owner <br /> -------l----- ; <br /> (If other than owner) . <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. BY__ <br /> - -- ---------------------=----- --DATE.---- <br /> DIVISIONOF LAND NUMBER --------------------------- --- -----=------ -------------- ---------� .----------------------DATE----------`------- <br /> ADDITIONAL COMMENTS------------------- ! <br /> i <br /> ----------- -------------------=----------- <br /> ---------------- --- -- <br /> - -- ----------- <br /> Final�Inspection by:------- ---- ----- <br /> ---------- <br /> ------------------------- <br /> Date._.._ " <br /> EH 13 24 SAN JOAQUIN L AL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />