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FOR OFFICE USE: FOR OFFICE USE: <br /> E APPLICATION FOR SANITATION PERMIT <br /> ------------ <br /> k (Complete in Triplicate) Permit No...... <br /> I <br /> --------------------------------------------------------- <br /> Date Issued-/ <br /> ------------- <br /> --------------------- ---- ------------------------------ <br /> _____"_-7-----_---_______-_"-----------------"_--______._____..__ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health 'Disfrict for-,a permit.to.construct and install the work herein described. <br /> This application is made in compliance with County,Ordin6n'ce,N6' 9 and=ex sting.R"_OA and Regulations: <br /> ' I -=---CENSUS TRACT"- ----- ---------- <br /> JOB ADDRESS/LOCATION.__.,. �_- __.-� - - ---- t �--- <br /> Owner's Name - - - one <br /> ,/� - I?h <br /> Address---------------- -- -- { - --- -moi---------- -- "--- -"ity------------. ---- ------------ ------ ------- ---------- <br /> Contractor's Name----- r11 - °---------------------------------------- <br /> Installation <br /> -----=----- License #/_� -1 l Phone- ��t� // € <br /> f 0 T- <br /> Installation will serve: Residence Apartment House ❑ -Commercial ❑ Trailer Court]❑ <br /> i I- ° 96tel 0 Other- -------=------------- <br /> Number of living units_______ ______Number of bedroom s:._ .=__Garbage Grindex _______Lot Size- -- <br /> j --- <br /> Water Supply: Public System and name_--- y►� E }= F--------------------------- -- ------------------------------Privates <br /> k _- . .; <br /> Character of soil to a depth ofp3 feet. Sand ❑❑ 'i It❑;, Clay ❑ Peat ❑ Sandy Loam ❑ Cla y Loam ❑ ; <br /> Herd an Adobe !Fill Materia!_ { >".-: If_"es, pe-------------------------•------- <br /> • <br /> : <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings; etc. must be placed on reverse side.) <br /> f NEW INSTALLATION:" ,(No,septic tank or seepage pit. permitted if public sewer is available within:200 feet,) <br /> PACKAGE TREATMENT t t ` _ -- --- <br /> PACKAGE ]....SEPTIC TANK [ ] Size.----- =-----------=------ ------=--------- <br /> Liquid""Depth. <br /> Capacity:m <br /> ' - ------------- TeF-- .5 l <br /> `-_------i---- '_No. Compa dments------------------------- ------ <br /> ---- ;. -_____ _Distanceto nearest: Well _ ___� Foundation Prop. <br /> Line_____________ ---_----- <br /> LEACHING LINE, [;] Na, of Lines,:............ Length. of each.fins.--- <br /> ---- t -Total Length _ D___,_. <br /> D' Box --_ -"'__Type Filter Material,______` Depth Filter Materfi <br /> g t ` :-- t <br /> Distance to nearest: Well_._s -`-__ .y_=-=__Foundation-----------------?'_______.Property Line--:------------------------------- <br /> SEEPAGE PIT •[ I Depth ,9_,6.� _Diameter ,5- - " __Number---,------- -------------------- <br /> _Q <br /> Rock Filled Yes } No <br /> . . .. R k5 t <br /> p ---------------Rock <br /> ize -- // <br /> h- ----- ! <br /> I p tan extol neaerest: Well- [ n` 1 Y-- <br /> �� - �------=�,��--"�'�--�--� 4 F�undation----�- --=----------- --�-Prop. Line--------=------"------- - <br /> REPAIR/ADDITION (Preva Sanitation-Permit*.,:---_ •-'- _- � � ---_------.D{ate__-____:-____.:-_._'-______._--_�-�__-_:_____) $ <br /> Septic Tank (SpecifyRequirements]- = = .- I---------------------------------•------------==----------- -=-------------- <br /> Disposal Field (Specify Requirements)-- _. _ - --------------------------------------- -- <br /> ---- --------------- -- ---------- - - <br /> -------- - ----- ---- <br /> �9 <br /> ______p____ -----------'_ ------------------ ._ .__ <br /> (Draw e'xistin'g and required addition'on reverse side) '- i <br /> I hereby certify that 1 have prepared :this application and that the work will' be r 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 eirmif is'issued, I shall not employ any person in such manner as <br /> to become subject,to Workman's Compensation laws of. California.". _. <br /> [ <br /> - <br /> :Owner <br /> OvnerSigned --------------------- <br /> Title <br /> ------------- <br /> j J <br /> t : ___•BY s : <br /> (If'other than ow ... .-. <br /> # DEP#kTMENT USE ONLY I <br /> APPLICATION ACCEPTED-BY_=._-__-_- _ _/LG - --' <br /> --:----------- - DATE.: '�c� <br /> DIVISION OF LAND NUMBER------- = =----_.-=------ ----- ----- ---------------- --".DATE_.- ------------------ ------------------ ---- <br /> ADDITIONAL COMMENTS } ------1-- ------ ` -'------------------------------ <br /> -------------------------------------- -------- -------------------------------- - - ------------------------------------------------ --------------------------- ------------------ <br /> --------- <br /> --------- --- <br /> ---------=--------------- ----------------------- --- <br /> ----=---------------------------- -- --- <br /> � - -- - --------------- -- -------------------------------- --- ------�---- <br /> -------------- <br /> --- <br /> ------------------------------------ - _ --Final lnspection•bY. .1 -- ���--- ---=-=------ --------'----- -------------------------Date� --__ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 91677 REV, 7/75 3m <br />