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FOR OFFICE USE: FOR OFFICE USE: <br /> _ APPLICATION FOR SAN-1-TAMON PERMIT <br /> Permit No. <br /> -------- ----------------------------------- <br /> (Complete in Triplicate) <br /> ---------------------- -------------- <br /> ` <br /> �� Date 'Issued.---- ------------ <br /> --------a�.••.•-------------------------- ---------.---------------- 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 and Install the work herein described. <br /> This application is made in compliance with County Ordinance No.0549 and existing Rules and Regulations: <br /> JOBADDRESS/LOCATION---------- --- --------- ----------- ---- ------------------------------------ --------------------------------CENSUS TRACT-- ----- ----------- <br /> Owner's Name------------------- - - ----- ----- ----------------------Phone---------------- --- ---------- <br /> Address------------ -------- ------ -----'-------------- --------- ----- --=---- -------- -----City------- ---------- ---------------------- -----Zip------------_--- -------------- <br /> Contractor's Name-------------------- <br /> ' -- ---.License-#=----------------------------Phone-------"-------- ---- <br /> - --- --------------------- ------- -------- ----•-------- -- - -- - - <br /> Installation will serve: Residence ❑ Apartment House.❑• Commercial.0. Trailer-Court ❑ <br /> Motel ❑ Other---- =----- ------------------------ --- <br /> Number of living units:----.'.'.__-�-.Number of bedrooms------------Garbage Grinde�r-':,--------Lot 'Size------ ___---------___;s.,___r__..:_- ---_,--.____.___.___... <br /> Water,Supply:'Rublic System and name------------------------------------ -------------------------------------.----------- ------ - - --- -----Private ❑ <br /> Chpracter of soil to a depth of'-3 feet; Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam•❑ . ; <br /> Hardpan ❑ Adobe"❑ Fill'Material---- If yes, type e <br /> ' _ t <br /> (Plot plan, showing size of lot, 'location of system in relation to wells, buildings, etc_ must be placed on reverse side:] <br /> NEW INSTALLATION: N (No septic tank or seepage pit permitted if public sewer is available within, 200 feet,] <br /> PACKAGE TREATMENT �[ ] SEPTIC TANK [ ] Sizer----------------- -------------------------- ----Liquid Depth.------'--'---------------- <br /> Capacity ----------Type------ =Material---------------------------No. Compartments._ ,-i '--------------- <br /> Di stance <br /> --------------Distance to nearest: Well------------------------- ----_-__'_------Foundation-------.----- ------------; Prop. Line.::----.-------------------- <br /> . � � - • <br /> LEACHING LINE [ ] No. of Lines_ ________________________..Length of.each line------- -------------------Total length.___..___ .----------__-� <br /> i Q' Box . --Type Filter Material--------------------Depth Filter Material----------------- '-----------=-• ----- -- -------------------- <br /> Distance to nearest: Weil-------------------------- -Foundation-----------------------------Property Line-- ---- .............-. <br /> SEEPAGE PIT [ ] De th..__'________._Diameter-..-.______._ -.-Number______________--:_--_--------- t Rock Filled',Yes.❑ No <br /> p ❑ <br /> - <br /> Water Table Depth---------- ------------' -� -"-.-Rock-Size....----=-- 4 <br /> Distance towa ` '^ti ... * <br /> rest;Well- -i- ---------- "1------------------Foundation--- - Prop. Line <br /> REPAIR/ADDITION (Prev.'Sanitation Permit#--------- ------------------ ---'I`Date-------------------------------=-- -;----"} <br /> Septic Tank (Specify'Requiremen_ts]--------_''N � <br /> --------=-----------------------------=----------- ---------------- -------------------- <br /> Disposal Field [Specify,Requirements) ,------"-- - `-- ---- - ------------- :: ------------------------,--- <br /> ----------------------------- --------------- - ---------------------- <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that I have prepared this application and that the work will be 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 /> f <br /> ..I certify that in the performance" ofl.the work for which this permit is issued, I shall not employ.any person in such manner as <br /> to become subject to Workman's Conipensatiorn laws of!California;" n <br /> i <br /> Signed--------=---------------------------=- - --------::-- ------------------------------------ ---Owner <br /> By-'------------------ -------------------=------------' =---=----- ------------------------------ -Title----- ----------------- ------ •------ ----------------- - <br /> (If other than owner} <br /> FOR DEPARTMENT USE ONLY - <br /> APPLICATIONACCEPTED BY------------------ ---------- --------------------------- - --------------------------------DATE.----=----------------- ----- ---------- <br /> DIVISIONOF LAND NUMBER---------------------- - - - ------------ ------ ----------------------------- ----------------------DATE.------------------- ---------- <br /> ADDITIONALCOMMENTS-- ----------------------------- ----------------------------------------- .--------- ----------------- ----- -- ----------------------- <br /> } <br /> ------------------------------------------------------------------------------------------------------------------------ <br /> FinalInspection by=------------------ ------ --------------------------------------- - ------Date.------ ------------------------ ----------- ---- <br /> EH 73 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M <br />