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FOR OFFICE USE: FOR OFFICE USE APPLICATION FOR SANITATION PERMIT - --------------------------- -------------- Permit No.- ---- - (Complete in Triplicate) -- --------------------------------------------------------- Date Issued___ ___---�- .---.--____-----------------_-.----._- -------- ------ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ____ 0RTfQ CENSUS TRACT-------------_-.----------- 7- -r------- -/,1--------------'`---------- _ _ - -- --------------------------------------- .Phone--g-7 3 --------------------- M, --�- ---------- Owner's Name.----------- PS ca i I rU Address.--.----- ----City- N�'BC ----------------------Zip--------- � ----------- Contractor's Name �R �f ----License # ��atS----Phone--- 32 Installation will will serve: Residence [ (i Apartment House ❑ Commercial ❑ Trailer Court ❑ M'tel ❑ Other----------------- ---------------------------- Number of living units:--_--/---------Number of b Brooms..--2----Garbage Grinder___-.------Lot Size---f------v-X --- --------------------- Water --- - - Water Supply: Public System and narr[e--- ------ -- ----------------------------------------------- ----------------------- ------------------ -----------------Private [ Character of soil to a depth of 3 feet. Sand V Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Ad-obi❑ Fill Material------------If yes, type-_____------------------------ (Plot plan, showing size of lot, locatic n of sys em in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic t�nk[°� eepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ 1 SE AN C'! [ ] Size------ -----------=----------------------- ----------------Liquid Depth.-------------------------,� Capacity--i Type--------- -------------Material----------------- --------No. Compartments---------------------------------- Distance..to nearest ell-- ------------- ------------------ -------Foundation-------------------------.Prop. Line---------------------------�,: LEACHING LINE [ } No. of Li s_ ------- -- _-_--------- Length:,of each line---------------L)i...- ------.Tota! Length.---.----7-V�--------------------- D' Box ---- --Typ-6,F Iter Material-----f-12�DeptlHail,ter Material------ --------------------- ------------------ - Distances to ea rest: ell---.- (Sul_-------- de r p tY Foundation Pro er Line- ' Depth--------_- ---.Di6m .__ ter---- _,:�---------Number----------- -----_____ Rock Filled Yes ❑ No❑ SEEPAGE PIT [ ] Water Table Depth ------------------------- Rock Size •� iz Distance to nearest: ell--.---- - _------_----_------------------.Foundation----.-----________----.--.Prop. Line--------------------------- REPAIR/ADDITION .____------ -----REPAIIR/ADDITION (Prev. Sanitation Permit#----- ---------------------------------------------Date----- ---- ----------------------- ---- ---- Septic Tank (Specify Requirements) r'} C!4Ch------------TV----------- ........ Disposal Field (Specify Requirements) ----------- ------- Q-- -------------------- _ —-------------------- ---------------- ----------------------------------------------------- --------------------- ---------- ------------------------------------- ---- -------------- --------------------------------- ----- rr ------------------------------- ---------------------- ---------- ------------ ------------------- (Draw existing and required trddition on reverse side) hereby certify that 1 have prepared his application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules crfid Regulations of the Sa Irk Joaquin Local Health District. Home owner or licensed agents ysignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not a ploy any persol in such manner as ! tb become subject to Workman's Compe ation laws of California." [ I ► Signed---- -------- - -------- ----------------------------- ----Owner �� /� --------Title--------- '------- (If other than 'owner) FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- - -- ---- -- - - ------ ----- - ---------------------------------- ----DATE.---- ------- ------- -------- ------------ - - ---- - - -- DIVISION OF LAND NUMBER---------- - ------------- - - -- -------------------- DATE ADDITIONALCOMMENTS------------------ ---------------------------------------------------------------I------------------------------------------------------------ ------------- - ------- ------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- ---------------- --------- ----------- - ---------------------------------- -- ----------- --- ---------------------------------------------------------------- -- --Final� ------------------------------------------------------�..."----- rte -- __- lrls�pectlon-6y: ---_=------ - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT {� t F8s 21677 REV. 7176 3M