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5 fe <br /> ' FOR OFFICE USE: <br /> FOR,1OFFI E USE: <br /> X -0" I� APPLICATION FOR SANITATION PERMIT y y <br /> Permit No----- -- ---- --------- <br /> 3 - (Complete in Triplicate) <br /> °------- --------- - Date issued_ <br /> This Permit Expires 1 Year From Date Issued <br /> Joaquin Local Health District for a permit to construct and install the work herein described. <br /> Application is hereby made to the San <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION. L - --- CENSUS TRAC(T`� <br /> � - - Phone -T - 7 _ <br /> f'1���._/ �- ----- <br /> Owner sName.--- -- -- -- --- --- ------ <br /> '� - ----------- ----- ----City- -- --. ... - --------- -------zip------ ----------------------- <br /> Address- ------- -------- ; <br /> Contractor's Name__ --- -_-- -- - <br /> ._ _. = ' _.---_License # :.5'9`3-------Phone <br /> __` <br /> Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------------- ---------- ------------ I r <br /> x <br /> Number of living units:------ <br /> of bedrooms------------Garbage Grinder------.__--Lot Size----- a-_- -- d <br /> -------------------------------- <br /> Water Supply: Public System and name---------------------- - - ------ ------ <br /> ------------- - -- - <br /> write _ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy LoamCla Loam <br /> Hardpan ❑ Adobe Fill Material_---------If yes, type-------------------------------- <br /> (Plot plan, showing size of lot,"location of system in.relation-to well s,.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 /> SEPTIC TANK [ ] ----Li Liquid Depth ---.---------.--'•------- <br /> Capacity_.. <br /> ------ <br /> PACKAGE TREATMENT [ ] Size-- -------- -------- ----------- -- ----- ------ q p _ - <br /> -------Material-------------------------No. Cornpartm'ents------- ------------- --- <br /> -------------- <br /> Distance <br /> -' <br /> GapacitY- ------------- --Type 1 <br /> Distance to nearest: Well__------------------________---------------Foundation------------------- ----v:Pr.op. Line-------------- ------- -- <br /> LEACHING LINE [ l No. of Lines-----f---------------- Length of each line-.-__------ -:-:--------------Total Leitgth------------------;-------------------- <br /> 'D' Box------------Type Filter Material------------------- Filter Material_-___,_-'_i_'-t,=•-_=: -- <br /> -------------- <br /> -----------�-------- <br /> Foundation -�= Property Line------------------------ -------- <br /> Distance to negr�st�Wel.l.�______________.�.--- - . <br /> %,l I Rock Filled Yes ❑ No <br /> SEEPAGE PIT I l Depth----------------Diameter....I-----a- -------Number------------ ----- -- <br /> _ ''Rock Size------------------------------------------------ <br /> Water Table Depth.-------- <br /> - `. `' t`' ------------ <br /> Y Foundation---------------- x-- Pro Line----------------------- --- <br /> Distance to nearest: Well------------- p' <br /> Date.,-,. _ s>, E_4...., -------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_____--- ------------------------- to f e � ;'" <br /> r _" r----------- ------------------------ ----- ------------- - <br /> Septic Tank (Specify Requirements)---------________-------t . --------------- <br /> --------------------- <br /> _._-__ _ ' <br /> Disposal Field (Specify Requirements)-------- <br /> ------------------------------------------------- <br /> ___ <br /> -" --------------- <br /> --------- <br /> yr --- + - <br /> „„ ---------- <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 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 become subject to Workman's Compensation laws of California." <br /> -------- <br /> f I <br /> Owner <br /> Signed----------------------- ------Title----- ------------ ----------------- <br /> --- ----------------------- <br /> _ - ------------------ ------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY' <br /> DATE.3 �.----"- -"-------.- <br /> APPLICATION ACCEPTED BY -- - -- - - - - - � ------------------------- <br /> DATE -- ---- --- --- -------- --------- -- <br /> - ,_ S"-- <br /> _ <br /> DIVISION OF LAND NUMBER----------------- -------------------------- ----------------------- <br /> -------- <br /> ADDITION L C9MMENTS ------- -------------------------------------------- --------------------------------------------------------- ----------------------- ----- ----- <br /> - <br /> 7 _..- Y 611-4---^------------------------------------------------------------------------------------- ----------------------- <br /> ------------------- <br /> ------ -- ------ ------ <br /> ------------------------------------------------------------------- <br /> ---------------------------------- -- - - - <br /> Final Inspection b �- �; --- - - ---------- ---------- --------- -------- --- - - <br /> Date_ -------j-=-3?Z--------- --------- - <br /> F&5 21677 REV. 7175 3M <br /> EH 13 24 S JOAQUIN LOCAL HEALTH DISTRICT <br />