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6 <br /> FOR OFFICE USE: "� �� ` FOR OFFICE USE: <br /> rAPPLICATION FOR SANITATION PERMIT <br /> ------ - ----- ------- ------ , <br /> - r <br /> (Complete in Triplicate) Pe mit <br /> Date Issued--- <br /> ----------- <br /> -------------------------­­---------------------------- <br /> ssued._ ---:_-----___"____________________________________________________ This Permit Expires 1 Year From Date Issued <br /> _ <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: i <br /> JOB ADDRESS/LOCATION : ".-------- --------------------------E -----°----CENSUS TRACT = <br /> Owner's Name..... '------------- - Phone <br /> 4 <br /> Address --- - -------- --- --- - -- ----- 'Cite - -- ---- 'p <br /> - r0 <br /> Contractor s Name ..-------- ------ - ---- iLicense #_f--� _ Phone r -- ld <br /> InstalIa'tion:will serve: Residence ❑ Apartlnen House.❑r Commerc Trpiler;Co'ur# ❑- <br /> i r..... .. Motel ❑ Other­F <br /> Number-of living units:___;_.- _ �___Numberof.bedrooms_,__ Garbag Grinder'___.____- Lot Size___k__f_�_______. Wit_._- -_- y <br /> Water Supply: Public System and_name-.: -' :y"°` Y-__. -".`.."..' -------------------=-------- <br /> Private <br /> $' <br /> Character of soil to a depth <br /> d 3aneet: Adobe Silt 4.te ial� Peat ❑Sandy Loam Clay Coam ��� <br /> p Q ❑ Clay <br /> P ❑ ❑ Fill Ma Ifily tYPe <br /> [Plot plan, showing size of lot, location of system in relation to,welIs, buildings,,etc.-must beiplaced on reverse side.} t <br /> NEW INSTALLATION- (No'"septic tank or seepage pit permitted if public sewer is available- vithin 200 feet,) 4 <br /> PACKAGE ' s �,7' r� 1 <br /> TREATMENT SEPTIC TANK " ize.___:_ " Liquid <br /> i .• <br /> It . /) •+Type Material_ _ No. Compartments._____ <br /> 1� Distance to-nearest:.Well . '' ��'t'* 'i ts` Foinda on. :__ 4_ f — Pro --------------- <br /> C <br /> } .� . 1 12 , r - <br /> LEACHINGiINE�[rF No, of Lines' _ �,•., Length..ofea{�ch line�-------�� � _._.____ Total Length.____�_�a.__ <br /> Box_ vType FiltertMa al__�Qa•. v_.DepthFilterlvlaterial_______.1 _ ---------------------------------------------- <br /> !D' <br /> Distance to nearest: Well____�0._=.-___..,_e:_Foundgtion Property Line._.___ �'_______ ! <br /> m -------- --- ---- --- <br /> SEEPAGE PIT [ } Depth.----- ........Diameter _ __..Numbe'r -_.________.._..________-__ Rock Filled Yes ❑ No ❑ <br /> Water Table-Depth---`------ ----------------------------------------------- <br /> - - - -----=- --------- -RockF Size ;�----,-�-------- ---------- <br /> - ' t _____ - ._ <br /> Distance to nearest: Well'': _ - L___O .ti_.____ Foundation1Tr�. Prp,�Lirle`a_ ____ _______________ { <br /> REPAIR/ADDITION (Prev, Sanitation Permit# = = f=�=.Date- ---- ------------------ --------- � <br /> Septic Tank (SpeacS!fy Requirements)----------- ---- -=-- --------------------------------------------------- ---- --------------- ------- — ------------------------- <br /> Disposal Field (Specify�Requi a nerltsf t--1---------------- ---- ---- ------------------f'------------------------------ --------- ----------- "+ <br /> 1 <br /> f 1Y ---- �3 <br /> - .a ------------ --------- <br /> -------------------------------------------------- ` <br /> j <br /> "hot <br /> r� , {Drab existing and*equ-,red d-ddition-on_r�r� side}'t-. fir, <br /> I hereby.certif� that_1-have pre ares this'.applicatyon and that the kwork,will be-done in accordance with San Joaquin County F <br /> Ordinances,; State Laws, and'Rules. and jRegula`tions of the- San Joaquin Local Health District.Home.owner or licensed agents <br /> Sign-, <br /> certifies the fallowing: I k <br /> "I certify thatjin the performance of'the work for which this"permit is issued, I shall not employ any person in such manner`,as <br /> i 4 � #'y.� ara <br /> to become subject to'Wcrkman's Compensation laws,of*California. <br /> Signed - -- -- ' _ :Ownera; y, . <br /> By 1- - Titles. Cr l - ------ ------- -- , <br /> [ i (I other than owner) : "r <br /> i r ; F DEPARTMENT USE ONLY, <br /> APPLICATION ACCEPTED BY_- .: <br /> ------------"---DATE.-- <br /> DIVISION OF LAND NUMBER:-------- - - DATE-------------- <br /> ADDITIONAL COMMENTS----=--- ----- --------------------t---------- , <br /> --- -- <br /> _ i <br /> - - -------- <br /> �`"� t � _ -}k f ------�-t <br /> - <br /> ------ ----------------------------------- --- --------------- <br /> Final ;Inspection-by:-- -.-- --- -- -- ------- •=--=-----"---- ---------------------------------=-------Date- X. l �� ------------ <br /> Final,; <br /> ----- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FBS 21677 REV. 7176 3M <br />