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- FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <br /> = <br /> --------- ----------A11 <br /> ----------------- <br /> --------------_ This Permit Expires] Year From Date Issued Date Issued <br /> 0 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> i JOB ADDRESS/LOCATION .__ ` _3 S <br /> -- --- - -- ---------- - - - -- �-�, -- CENSUS TRACT --- ---- •---•--••---- <br /> Owner's Name -------- r "�"`�''�– <br /> -------- -- -- - ------- ----------------------------------- - ------- - --- Phone ------ ------ --...-----•-•-•---- <br /> Address ------ ---- ------------------------------------ ................. <br /> ---------- <br /> „�`��.S--- - -' ------ - ---- •---- - - -- --- - �--- �... City <br /> Contractor's Name -�-- _�--- --------------- -------------- ---------License #�_ .,_.may_ Phone <br /> Installation will serve- Residence Apartment House ❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ---------------------------:----------------- <br /> Number of living units:---- ----- Number of bedrooms-- '? Grinder ------------ Lot Size ____________________________________________ <br /> Water Supply: Public System and name ---------------------------------------------- ------------------------ ------------------------ ------Private M <br /> f <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ . Clay ❑ Peat❑ Sandy Loam ❑ Clay"Loam ❑ <br /> Hardpan P' Adobe '❑ 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size___________________________________________ ___ Liquid Depth ______________________._-_ <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----------•--• 1l� <br /> ' Distance to nearest: Well ------------------------------------- <br /> tFoundation ---------------------- Prop. Line------------.._.-•--•-- � <br /> E LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length ---------------------------- TrI <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material ________________________________ ............ ' <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ________._______-------- <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ----------------------------- Rock Filled. Yes ❑ No I❑ <br /> Water Table Depth -- --------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ..................... 1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------ . Date .-.-------------------------------) � <br /> Septic Tank (Specify Requirements) ---------------------------- ----------------- <br /> Disposal Field (Specify Requirements) ----('_�_ <br /> ------------- <br /> G - <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 <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents 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 <br /> as to become subject to Workm 's Compensation laws of California." <br /> Signed --------= -------- - �- --- ---- = A -=- ------ _-- ---=-- Owner.._. „.�_.� Y _ <br /> --- ---- ------ > . Title -_�`t ° ""'Arm � ------ --r <br /> -------------------------------- <br /> (If other than o ned- , <br /> AOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- -------- --- --------- ----------------------------------------------- DATE _- .— --------------------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------- ------------= ` -----------------------DATE ------------------------------------ <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------`-- -------------------------------------- ----------------------------------------- <br /> ------------------------------- -------- --------- -----------------------------------------------------------------------------------------------------------------------------------••----------------- <br /> ---------------------------------------------------- - ------------------ -------------------------------------------------- ----------------------------------- ---------------------------------------- <br /> i <br /> Final Inspection b Dated a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />