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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------- <br /> (Complete in Triplicate) Permit No-2-2 ---------- <br /> ------ ----------- ---- --- I <br /> --`3------------------------------- <br /> ------------ <br /> Date Issued-z------�'---- -- � <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 /> JOB ADDRESS/LOCA !ON_ vZ_ 9....-.zp_.�_ __ . . ........... --r -------.CENSUS TRACT <br /> 0 ---------------------- <br /> Owner's Name..- .. _ _-- ----- ---. - Phan <br /> Address------------------------ --- ------- ---------- -------------------- Cid --------------Zip----- <br /> ------------------------- <br /> ,�ryry PP�� <br /> Contractor's Name._A _ &---.&... ... t✓�-ria-_.yC-- --. _License # Y -----_Phone-_ _ <br /> Installation will serve: Residence)< _Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_-- ---------------- --------- -- -- ---- <br /> i <br /> Number of living units:.- . . .......Number of bedrooms__- Garbage Grinder....... ..Lot ize-... . <br /> f ' ------------------ <br /> Water Supply: Publi.,c System and name._..-_-- i "..rGC12t____ Y-c.r __Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy oam ❑ Clay 0Loom <br /> � <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---------------------------------------------- .Liquid Depth ------------------ <br /> R CapacityType -----Material--------------------------No• Compartments <br /> Distance to nearest: Well.-.----------------------------------------Foundation--------------------------Prop. Line---------------------------. <br /> LEACHING LINE [ ] No. of Lines-----------------------------Length of each line-----------------------------.Total Length.---------------------------------------tA <br /> 'D' Box_----------_Type Filter Material__-----------------Depth Filter Material-------------------.------------------------------------------- <br /> Distance <br /> ___.._._.__.__. -__-_-__._-Distance to nearest: Well .-----Foundation----------------------------Property Line_...._-..____-.-------._.-_----- <br /> SEEPAGE PIT [ ] Depth----------------Diameter---- ---------------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth------------------- - -------------------------- ----Rock Size--------------- ------------------ <br /> Distance to-nearest; Weil--------------------------------------------Foundation-------------------------.Prop. Line---.----------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Pe t#--'- ---------------------------Date.____.--------------------------------------- <br /> Septic <br /> _____.._. ..________-_..____Septic Tank (Specify Requirements)----- - - ------------------- --- 7 ------------------------------- --------------- --- -------- --- <br /> Disposa Field (Specify RAuirement ------ --- --- ----------- r "� � - --------- <br /> -- ------- -------- - - --- <br /> ---- --- --- ------------------------------------------------------ ----- -- -----------------------If-------- ------ -------- ---------- -----`'---'Q-------------- <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 /> 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 t e erformanc4othe work for which this permit is issued, I shall not employ any person in such manner as <br /> to become ubjec Work anpe sation laws of California."Signed-----/ �tt - ------ <br /> By--------------- -------------------------------------------- -- - --- ----- ------ TitleA <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------- ---- -------------------------------- DATE. r 7----- - ------- <br /> DIVISION OF LAND NUMBER11� ----------------DATE-------------------------------- ---- ------- -- <br /> ADDITIONAL <br /> ------------------ ----- <br /> ADDITIONAL COMMENTS---- ------ ----- -- ---------------- ------------------------------------------------ ------------- ---------------------------------------------- <br /> N --------------------------------------------------------- <br /> -...---------- <br /> FinalInspection by:------------ r - ---------------------------------------------------- ------------------ -------Date/f -------- ---- 1 --------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 71763M <br />