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FOR OFFICE VSE; FOR OFFICE USE: <br /> � APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit Na.. .-..:. ..--.. <br /> ---------- ----------- -------- <br /> Date lssued_��6- <br /> - This Permit Expjres 1 Year From Date Issued <br /> A lic t n is hereby ` ade to.the San Joaquin Local Health District for a permit to construct and.install the work herein described. <br /> This application is-made �In�pliance with,County Ordinance o. 549 and exist ,g Rules and Regulations; <br /> JOB ADDRESS,AQCATIOql <br /> ------------------ -- CENSUS TRACT <br /> Owner's Nom al`,� <br /> Address- &O/.... . ........ . . . City . ziP lam,? ...... <br /> Contractor's Name---- --------- - -----License #........... Phone--............. <br /> Installation will serve; Residence)< Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other............ - <br /> Number of living units----- --------Number of roo s,2__ rbage rin er. ....- ...Lot ..1 l� --.-_-.-,----.___- <br /> Water Supply: Public System and no �� � <br /> •------•Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay jPe, t ❑ Sandy Loam ❑ Clay Loam ❑ , <br /> Hardpan Adobe <br /> p ❑ Fill Material _.,,.. ....lf yes, type --- ................ . -------- <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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] size ... -. -..... ------------------ - --Liquid Depth-------.-................ <br /> Capacity--- ------ ..........Type=............... <br /> ..... Material-------------- -----------No. Compartments..-...:.-.- ...... <br /> Distance to nearest: Well-----------------........... .... .......-"Foundation--------- ...... _.Prop. Line..................... <br /> .--. -. <br /> LEACHING LINE [ ] No. of Lines ---------------------------Length of each line----- <br /> ./__---- <br /> Total Length---------------- .. _-.......-.................. -... <br /> 'D' Box_....--....Type Filter Material......... .....---..Depth Filter Material...--.-.-..------- ---- ­_ ---- --------------- <br /> -.-... . <br /> Distance to nearest: Well. ......................Foundation---- ---------------- ......Property Line.--------------- ------- --------- - <br /> SEEPAGE PIT { ] Depth............. _Diameter.___..___------ *Number--_- ----------------- Rock Filled Yes ❑ No <br /> WaterTable Depth------------------- --- ------------ -.Rock Size...................- ----- ...................-- <br /> Distance to nearest: Well------------ _ -- ..-----------Foundation................ ._......Prop. Line---.--------_-........... <br /> REPAIR/ADDITION (Prev. 5anitation P t#-----------------•------ ------ - --------..Dat -.- ....-•... .......... - ............. ' <br /> Septic Tank (Specify Requirements)_._. _ . .. -----------------_ . <br /> .. -- -- <br /> Disposal Field (Specify Requirements) . ,�_�.......I........ <br /> -..-------------'.........'----------------------- F.. <br /> ---•--------•----'................... ................----------------- ------------................... . <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work v011 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 /> "1 certify th the performance of thA work for which this permit is issued, I shall not employ any person in such manner as <br /> to beco a sub' Workman' C' e sati laws of California." <br /> Signed y ----- Owna <br /> &y.. Title------------ ---- ................ ; <br /> If other than owner) <br /> PPR DEPARTMENT USE ONLY <br /> DIVISION OF LAND NUM$ER..... - -DATE <br /> APPLICATION ACCEPTED BY....- DATE ..._ . ..7..7F <br /> G �i�t�L�._.."t Z_ ..C67JCsC.. ......... <br /> ADDITIONAL COMMENTS....................... <br /> �,,}, �p <br /> ..-- -- ...................... ---------- • -----•--------------------------------­­ - -- ......... --- . <br /> - - - <br /> - <br /> Final Inspection by:......... Date . <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F&S M77 REV. 7/76 3M <br />