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T FOR OFFICE USE/ <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No----------------------- <br /> (Complete in Triplicate) 7 <br /> `* Date Issued-- ----------------- <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin <br /> County Health <br /> Disce trict <br /> afor a nd existing Rules and Regulations:ermit to construct and install the work herein described. <br /> This application is made in compliance w Y <br /> L,L _i ---------------------CENSUS TRACT ------ ----------------------... <br /> JOB ADDRESS/LOCATIO .------ /---� , " <br /> ------------- <br /> Owner's <br /> � <br /> ...................Y-...-...__..-..__..---._...__.-__.. <br /> -- - ------ -- -- �----Phone--- - ------ -� -- - - <br /> Owner's Name ° ----- -------------- <br /> -- City--- - -- <br /> License SSF,r 3 Phone <br /> Contractor's Name---------- -- <br /> J -� <br /> Installation will serve: Residence [f Apartment House.M <br /> Commercial ❑ Trailer Court El <br /> "Motel Ej 'Other-------------------------------------- ------ <br /> Number of living units -._..Number of bedroom s_�--Garbage Grinde,r------------Lot Size <br /> ---- --------- ------------------ <br /> ------------------- <br /> Private <br /> Water Supply: Public System and name. -----�---------- ------- --- -- -- <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay E] Peat[I Sandy Loam El Clay Loam <br /> Hardpan E] Adobe Fill Material;..._.---..__If yes, type-------------------------------- <br /> ; ,,. , <br /> 1 <br /> (Plot plan, showing size of 10;,septic tank or seepage <br /> of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> (No e pit permitted if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: <br /> PACKAGE TREATMENT <br /> SEPTIC TANK [ ] Size-.- Liquid Depth <br /> ( ] <br /> Capacity---------------------Type-------E---------------Material--------------------.--.--No. Compartments----------------------------------- <br /> Distance <br /> ..------------------ ------------Distance to nearest: Well ---------------------------=--------------Foundation--------------------------Prop. Line------------------------1 <br /> LEACHING LINE [ ] <br /> No. of Lines --.---.Length of each line-----------------------------Total Length__------------------------- <br /> 'D' Box------------Type Filter Matefial...................-Depth Filter Material-------------------�----- --- --- --- -- ------- ------ <br /> i ----�-.Pro Property Line----------------------- -- <br /> Distance to nearest: Wel!---------------------- -----Foundation_----- ___---..__----- -----• <br /> . _ Rock Filled Yes ❑ No I <br /> SEEPAGE PIT L l Depth Diameter--------------------Number---------s'--- -- -- <br /> �~ '---.Rock Size----------- ------------i------ -------- <br /> Water Table Depth.--------- --- ------------------ <br /> ! ------.Prop. Line--------------------------- <br /> ---- -- �Faundation.-: <br /> Distance to nearest: Well................----------------------- <br /> REPAIR/ADDITION <br /> ... . .. . <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------------------ <br /> -------------------- ------ -------- -- ---- - -Date---- ------. ------ ---------------- <br /> Septic <br /> -------- ------Septic Tank [Specify Requirements)-"t <br /> ----------- <br /> ` --- c`cr.�`."------------------ <br /> Disposal Field (Specify Requirement ).._---------------- <br /> o ' a-�- -- ---- ---------------- ------ ----------- <br /> --------------------------------- ---- ----------------------------------- - ---------------------------- ------ - - <br /> --------------------- <br /> ---- ° <br /> (Draw existing and required addition on reverse side) <br /> licad that the work will be done in accordance with San Joaqu <br /> I hereby certify that I have prepared this app in County <br /> tion anof the San Joaquin Local Health District. Home owner or licensed. agents <br /> Ordinances, State Laws, and Rules and Regulations <br /> signature certifies the following: <br /> permit is issued, I shall not employ any person in such manner as <br /> "1 certify that in the performan of the work for which this <br /> to become sutt�o Work <br /> b� Compensate I ws of California." <br /> �(} ! a—� wner <br /> Signed--------------- -----` =------ ------- -------- - <br /> .Title------- - --- <br /> _____ __ ----- <br /> By <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> ------------------------------------------- <br /> DATE.._ 7 7 <br /> ------------- <br /> APPLICATION ACCEPTED BY--- ------------ -- - --• <br /> -- --- DATE ----------------------------- ------ ------- <br /> DIVISION OF LAND NUMBER -------------------------- -------- -------------------------------------- <br /> ------ - <br /> ADDITIONAL COMMENTS----------------------- -- - --------------- <br /> ----------------------------------------------------- ------- ------- ----- -------------- -- ----------- ------------ <br /> -----P-- --- <br /> - --- - Date.7.-. -- 27----------- -- <br /> Final Inspection by:.- <br /> - - ----- ---- -- ---- - - <br /> --- - _ . l--...-- F&S 21677 NEV.7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />