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Ff <br /> IN <br /> FOR OFFICE USE: "'.'` F©,R OFFICE;OSE: <br /> APPLICATION FOR SANITATION PERMIT <br /> = 7� _ <br /> (Complete in Triplicate) Permi# <br /> t <br />� ------------------------------------- -- - d� J*_ 7) <br /> ---------------- .Date Issue -'-- --------- - <br /> i <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 ainstall the-work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules annd d RegulationsT: " <br /> k JOB ADDRESS/LOCATION.__,:.___ ___ ------------------------------------CENSUS TRACT--------------------- ------ <br /> Owner's Name.-- Phone <br /> G ' <br /> 4 .. ...�. <br /> s. <br /> t, Address----------- ' ------- -------- '----- ------ --------------- --------------------------------- - ---- ------------------------------ <br /> C-�, % Zip <br /> Contractor's Name----------- ---'---------------License # -� L ' -phone--g- <br /> 4 <br /> - - _ <br /> _ . <br /> Installation wiII-serve: Residence Apartment ose.❑Commercial"❑ 'Trailer Court ❑ <br />{ Motel Other----- -------- <br /> ---------------------------- <br /> N <br /> ----- = ' <br /> Nulmbar of I � ❑ � 1 -=--- - �'-yy <br /> living units:- -----_Number of, Garbage Grinder------------ Size____. /L _V 7t9_____________-- <br /> Water Supply: Public System and name----------- ------------------------------------:---------------- <br /> ---------------- ------------------------Private IN, <br /> y <br /> I <br /> Ch a7racter of soil to a de ❑ E]pdaof 3 feet:, Sand Silt Clay E] ❑ <br /> Pea#' �.- Sandy pm ❑ Clay Loam <br /> dean D. Adobe ❑ Fill Material-------------If yes, type--------- --------------------- ' <br /> (Plot plan, showingsize of lot, location of sysfem in .relation to wells, buildings,.etc. must be placed n reverse side.) <br /> NEW INSTALLATION:-,�.e ^s <br /> (Noeptic }tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT�- �]-, `SEPTIC TANK [ ] Size-------------------------------------------------------------------___Liquid Depth------------- <br /> r C^f acit t r <br /> s P- Y j'------ ------TYPe---=------ Material = Na. Compartments <br /> - <br /> }r Distance to:nearest: Well----------------------------- -_'Fouricidtion ___...---_:-----i -:--Prop. Line-------.--------------i-- n <br /> LEACHING LINE. [ ] No. of Lines_.-_, -- Length,of each line------ a ""----__-Totpl Length.___.,_ --------_ <br /> } ''D' Box- �---- ---.Type Filter Material--------- --- -- --Depth Filter Material_�'----------------.-'---------------------------------------- <br /> - <br /> } <br /> t � L J <br /> 1 - Dista ce.to nearest: Wel!___ y�_ _ _______ undation.__.__�`_ _--_________.Property Line-_--/�--------____.__."-:---. <br /> k [ ] Dep[VVX1-Wd eter--;-----------------.Number---------,i------------------- Rock Filled Yes ❑ No❑ <br /> .eWarer Table Depth-------------------------------------------------= ---Rock Size. -------{-------------------- <br /> { Distance to nearest: Well-------------------------------------------.Foundation-- -- -__---.Prop. Line----------- ----- <br /> --------- <br /> REPAIR/ADDITION(Prev:Sanitation Permit#----------------------------- ' <br /> s Septic T :k(Spekify Requirements)------------------ :-- ----- - <br /> P _ , <br /> l Id {Specify Requirements)-----.:-- --- - - ---------------------------------------------------------=---------------------------------"--------------------- <br /> Disposal Fie <br /> ------------ <br /> --------- -------------------- ---- --------------------------------------------.----.----------------------------------- .---- --: --------------- <br /> t ------- --------------------------------------------- ------- ---- ----------------------------------------- - ---------- <br /> (Draw existing and required additio-n'on reverse side) <br /> I hereby certify,that l have prepared this application and that the -work will be done in accordance with San Joaquin County <br /> r Ordinances, State-Laws,a d Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> F signature certifies the fo I inning ! a , <br /> 4 "I certify that in the performance of'the-wgrk for which-this permit is issued, I shall not employ any person in such manner as <br /> I to become subject to Workman's .Com atio'n-laws-of'California.:' i <br /> Signed--- <br /> - - ---- ------- -= ---------Owner <br /> iBY-S--------- ---- - --- -- ---- -------- -- ---- --- -- - -- ------- - -------- - ---- Title---------------------------- ----------------------- -------------------- <br /> 1f Other than owner <br /> i -FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY___ <br /> --------------------------------------------------------_ --------DATE..---,3-------------------------------------- <br /> I DIVISION OF LAND NUMBER------------------------- ---- DATE---------------.__.----------------------- r <br /> - -�_...- <br /> ADDITIONAL COMMENTS----- ------------- <br /> -----------------------------------' ` = - _ .. <br /> -------------------------------------- --------------------------------------------,---- _ -----.-----_----------- - <br /> I ------ <br /> ------------- -------------------- --------- - , :--------------- ---- ------------------------------ -------------------------------- <br /> ------------------------------ <br /> ---- - - <br /> r-----=------- ---------- - ------------------------------- ---------------------------------- -�----- - ------ .-- --- <br /> 0 <br /> Final-Inspection-by.---- - r�° _ ---------`---- Date --- --- --- ------------- <br /> --------- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M <br />