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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- .-- -- -- <br /> (Complete in Triplicate) Permit No.-- .... :'71� <br /> ............. <br /> ... ......-. p Date Issued.._79.-- <br /> :E. <br /> This Permit Expires 1 Year From Date issued { <br /> 4 <br /> Application is hereby made to.tlhe San Joaquin Local Heal h District for apermit to-construct and install the work herein described. . ' <br /> This application is made in com°�Iiance with County Or ante No. 5and existing Rules and.Regulations: <br /> JOB ADDRESS/LOCATION. . III.LJI'� CENSUS TRACT---------.-.................. <br /> ------------- <br /> Owner's Name.... .._ - -- ------Phone_.......... ....... <br /> Address �M ......City------- ---- -------- ------------------- --Zip........................ ' <br /> Contractor's Name...__.- - .-- --...License #... Phone.P. .� 7 <br /> Installation will serve: Residence �o`teApartment House ❑ Commercial E] Trailer Court ❑ <br /> `M ! <br /> E] Other-.... - ........... <br /> Number of living units:------ <br /> !.Number of bedrooms--.0- ..Garbage Grinder------------Lot Size_....... <br /> II _ ----- .......... --- ----------------- - i <br /> Water Supply: Public System and,name.. ...................•---�,-,-- -. - - --•-- Private ❑ s <br /> it , <br /> Character of soil to a depth of 3 feet; Sand ❑y .Silt b Clay ❑ Peat [] Sandy Loam Cj Clay Loam t <br /> Hardpan ❑ Adobe Fill Material . .... ....If yes, type....._...................... <br /> (Piot plan, showing size of lot, location of Sy'st'emin relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic .tank orseepage pit permitted-if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [� Size.......-'-,�D- -�'------------ -----------------Liquid Depth-------- <br /> , .I; � - - --- <br /> Capacity,16."_.... -.--Type .... ...�k�....Material..�?!��------------..No. Compartments... z..._ c' <br /> --------- <br /> LEACHING Distance`to nearest: Well-..--S�O.___..... .. .....:. ..-•-.....Foundation-.._..10. .............Prop. Line....��..._. . _..._..... <br /> G LINE jrJ No. of Lines ...__ .._----------------Length of each line ........... - ._ .. .-,Total Length .._............. ........ <br /> # Y Box._ .Type Filter Material..00lP,&f9..... .Depth Filter Material.: ... ........... . ....... <br /> Distanca.to nearest: Well... .._.._...........Foundation---J0-- ..k.........Property Line...`------------------ <br /> ........... <br /> retgr--- - Rock'l YeZNo <br /> P :�-Number= ----,.------ --. <br /> Water Table Depth._./0.6............. ... . ............. . .........Rock Size.. '_ ... .-_--------------------. .- � l <br /> Distance to nearest: Well.-.__/e49...... .....................Foundation--.-.,✓.A.................Prop. Line..S ...-..... <br /> -- --.- •- <br /> REPAIR/ADDITION (Prev. Sanitatiibn Permit#..................:.. ..... .-.-.Date..........- -------------------- ) <br /> Septic Tank (Specify Requirements).--.... .. ..� <br /> ----- ..... <br /> Disposal Field (Specify Requirements)._,.. <br /> ­- --------------- - -- <br /> (Draw existing and required addition on reverse side) <br /> I herebycertify that I have + <br /> Y prepared this application-and that the work will be done in accordance with San Joaquin County <br /> Ordinances, .State Laws, and Riles 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 no! employ any erson in such manner as <br /> P <br /> to become subject to Workmanil Compensation lows of California." <br /> a <br /> Signed--- <br /> ----------- Owner , <br /> BY `" ......... <br /> -;, Title.............. <br /> (if other than owner) <br /> !I� FOR DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED BY..---- lit . DATE ...: ."�- '1.. <br /> - -------- -------------- -------------:-----------.-----------•------ <br /> ...................... <br /> DIVISION OF LAND NUMBER ,,---_ll-------- ------ .--....-- ....... ----.DATE.-- ....... ...--- <br /> ADDITIONAL COMMENTS.-......._.I.i <br /> --------••------ -• .................... <br /> ill .... <br /> ... . ............ . ------ ....... --------- .- . . . <br /> ------ --- -- - ---- - ------ <br /> ---- ; ... .... <br /> Final Inspection by; ..... - ........ ' <br />