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FOR OFFICE USE: FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No........_�...:...._._. <br /> ................................................ _ <br /> Date lssued...s.-"� .?� <br /> This Permit Expires I Year From Date Issued <br /> Application is hereby made to.the SanJoaquin 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. 544 and existing Rules and Regulations; <br /> pp Q <br /> JOB ADDRESS/LOCATION _.. l�/ ,--••--.-. /7/L�„,. NSUS TRACT........... .................... <br /> Owner's Name........r,.... - <br /> �._. ...�......,............... .......Phone.............. ....................... <br /> Address..................�I D D.o Z1 <br /> ...-- �� t.....:.........Ci <br /> j Contractor's Name...... .. ......................License #............................Phone.......:.......................... <br /> Installation will serve: ' Residence Apartment House ❑ Commercial Q Trailer Court Q <br /> Motel ❑ Other............. <br /> Number of living units:................Number of bedrooms........ ...Garbage Grinder........._Lot Size..................... .... ... . .,. <br /> Water Supply: Public System and-name.. .......................... . . Private, <br /> Character of soil to a depth of 3 feet; Sand ❑ Silt 0 Clay E) Peat E] Sandy Loam Q Clay Loam <br /> Hardpan ❑ Adobe Q Fill Material.. .... ....If yes,type........................... .. . <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,etc. must be placed on reverse side.) O� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer ii avoi dable within 200 feet,) <br /> PACKAGE TREATMENT ( J SEPTIC TANK ( 3 Size.............. .....:.....................................Liquid Depth............................ <br /> Capacity.....................Type.......................Material..................._.....:No.'Compartments._.._...:......._ <br /> Distance to nearest: Well..................... ..........:.......:..Foundation.......... . .......... ..Prop. Line........................... <br /> � <br /> LEACHING LINE ( l No. of Lines ----------------____-:......Length of each lin&------__-------7,............•.Total Length .. .................. ................. <br /> 'D' Box.............Type Filter Material........ ...........Depth Filter Material................... .............................. <br /> .._......_---- <br /> Distance.to nearest:Well............................Foundation............................Property Line................................... <br /> SEEPAGE PIT f I Depth................Diameter...........__.....Number......... ...................... Rock Filled Yes❑ No❑ <br /> WaterTable Depth............................... ................._.._....Rock Size.. .---......--•------... . •-----............ <br /> Distance to nearest: Well...........................................Foundation ......Prop. Line........................... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................. ...............Date..............................................I <br /> Septic Tank (Specify Requirementsl................. ................... ..... . ... . _._._.._.... j <br /> Disposal Field (Specify Requirements)........ Q_�i��i"""'L .. �..--.---:...,lltirX. ...........cY..., �J� %?!Y'�J...._............. <br /> ................................................. ... .......................................... <br /> ........................................................ ... --.............................................................._......_....------............_ .......... --................. ............ <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 <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "t 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 becom ub ect t W fk n's Compensation laws of California." t <br /> Signed. <br /> _..._.. . _. <br /> ....... .................... ..Owner <br /> By........................................................... .... Title ---.................... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY._ ..... .DATE .S"'> Y..'Z '..................... <br /> DIVISION OF LAND NUMBER................ s ................._..._..._.. DATE...._.........._. ::..._....... ................ <br /> DITIONAL COMMENTS........................... <br /> ......................... . ................. ............................................................................................... .•........................................... ........... <br /> ....-•-•....................._................ ..... .. I................................................................................._............_................._.........._..................... .. <br /> ... _ .. .....................................:..'........_.................._..._..............._.........._................ <br /> Final Inspection b . . �— 1s:7•••••. '_. _......._- <br /> y:...:.... . . .............................................. .......................... .. _ ....Date..... .......... .. ' <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 Rev. rrre inn <br />