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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No._ <br /> y c� <br /> ------------------ ----------------------------------- <br /> (Complete in Triplicate) j <br /> Date lssued,1Q._/..•..�_-�_ <br /> --------------------- ----------------------------------- This Permit Expires l Year From Date Issued <br /> I <br /> Application is hereby made to the San Joaquin Loc I.Health Distdct•_for,a permit to construct,ond*install-the work herein described. <br /> This application is made in compliance with County Ordinance- <br /> No. 54§and exi'stin 'Rules and'Regulbtions\, <br /> JOB ADDRESS/LOCA N---- _��.- 44 <br /> CENSUS TRACT :..... <br /> Owner's Name. ------------------------------- ------------------------------ --Phone ----------- --- <br /> AddressCity Zip <br /> Contractor's Name.- License Phone_ <br /> Installation will serve: Residenct <br /> Apartment House.❑ Commercial E] Trailer Court El.. tei ❑ - Other- ------ - --------------------- ------------- <br /> Number of living units:-----_ _______Number of bedrooms__,/(_---Garbage Grinder_...._--------Lot Size__j-Q... )t ,. 11--- I <br /> Water Supply: Public System and name-------- ----- -- -- ----------------:--- ------------------------------ ------------------- --------------- --------Private <br /> AVO <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan 0 . Adobe Fill Material------------If yes, type------- -------------,---- r <br /> i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must beiplaced-on reverse side.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available witl in'200'feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [:1 size <br /> - ---4tA.__.le ' ------------� --------� LiquidsiDep <br /> th.-----_---- <br /> CtmsCa acit -L 4 /---- - TYPe�--------- - Material ----------------------- <br /> ------------ <br /> Noomare � <br /> a- s <br /> Distance to nearest:_Well::_:... .. -----------. Fou.ndation-... ...------------s.-----Pro Line____. � <br /> LEACHING LINE: [ .] No. of Lines_;_;__ Length of each line.._ ,--_ �� L' -------------------- --- <br /> g �(_,____:....,.Total Length.=/- <br /> ' 'D' Box-----I_-;-_Type Filter Material-----1,o Depth Filter Material---1. ' 1------ ---=-------------------------------------- <br /> Distance to nearest: 1Nell-----�.°�-- Foundation--------------------------- <br /> ________ ________ �P,roperty Line__ _. <br /> SEEPAGE PIT [ ] Depth----9-. _-_Dia meter_ ��+_-----Number`--cam%... ..............:. Rock Filled Ye No ❑ � <br /> iWater Table ept�.---.----------------------------------------- -------.----Rock iz ',', <br /> ; . <br /> t Distance to neares : Well-----.�_ __.________......-... <br /> --.Foundation--------- -- Prop. Line----------------------------- �i <br /> REPAIR/ADDITION-(Prev..-Sanitation Permitj# <br /> ....---- ---------------------.---------------------Date ----=------------------------------- --1 <br /> SepticTank (Specify Requirements)-=--- -------- ------------=------=---=-------------------------- ---------------------=------- ---- ---- ---------------- ------- ----- <br /> Disposal Field (Specify Requirements)------------------- ---=---------------------- -------------- <br /> I ------------------------ ------- --------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done •in accordance with San Joaquin County i <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 permit is issued, I shall not employ any person in such manner as <br /> to became subject to Workman's Compensation laws of California." , <br /> Signed---- ---------------Owner , <br /> B ( ' x= <br /> Y Title------------ ---- -------------------------- -- -- -------- <br /> (If'other han owner) <br /> FORL DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED-B -- ------------------------------------DATE.-AC -------------- <br /> DIVISIONOF LAND NUMBER----?---------=---------------------------- ---- ---- ------------- --------------------- .------.-'-.DATE-- ----------------- ---- <br /> ADDITIONAL COMMENTS---------- -- - -- -------------- -------- <br /> -e 7� �! -------------- <br /> Final ,------------------------------------------ , <br /> - - - - ------------------------------------------ <br /> ---- ------ -------------------------- <br /> - --------------- --- - <br /> Ins Inspection:P Y - = Date---Z-6-r1 p--"7-QQ <br /> l � iFJ----------- ----- <br /> EH E3 24 U SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />