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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. -.2------------�� <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From bate Issued <br /> Date Issued -��------=-_--- <br /> -- --------- ----------- <br /> _------------- <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. 54499 ann-d- existing Rules and Regulations- <br /> JOB <br /> ADDRESS/LOCATIO CENSUS TRACT <br /> - <br /> Owner's Name -------------------phone ------------------------------------ <br /> ----- --- <br /> Address -------- --------------------- ---------------- ... City <br /> Contractor's Name - '�`:_ License # ./a - Phone <br /> Installation will serve: Residence Apartment House❑ Commercial []Trailer Court ',❑ <br /> Motel ❑Other ------------ ------------------------------- <br /> Number of living units:------ ..-- Number of bedrooms --�-Garbage Grinder ------------ Lot Size --- `-`--------------•--- <br /> Water Supply: Public System and name ---------------------------------•----------------------------------------------------------._--------------Private Q� <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan V] 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 -------------------------- Ob <br /> Capacity -------------------- Type -------------------- Material-------------- ------- No. Compartments ------ ------_---•-- W <br /> Distance to nearest: Well ------------------------------------Foundation --.------------------- Prop. Line ------_-------------. <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_------------------_----- Total Length ----_-_----------___ . <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------------•---- <br /> Distance to nearest: Well ----------------------- Foundation ------------------------ Property Line ---------------.--.----- <br /> SEEPAGE PIT [ ] Depth ---------A------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ----------------------------------------- ------Rock Size ---- --------------------------- <br /> Distance to nearest: Well -----------, ----------------------Foundation -------------------- Prop. Line ....------------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------- ------••------------------------ -------------------------------- <br /> Disposal Field (Specify Requirements) - -_ f - �'1'`'� 1 fes` ' ----------------------------- <br /> ------------ <br /> --------------------------------------- '''C° r � �"`° 'C'`- ----- 1 3 3''X------------------------------I-------- --- - <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------- <br /> ------------ - ---^- ------ ------------------------------- Owner <br /> 0 r� r -------------- Title ----�------ --,�' <br /> Y ------- ---------- ----------- -------�------ - <br /> ----------------------------------------------- <br /> (If other than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - Y <br /> - ---------- ---- ------------------- ------------------•------------- - ----. DATE �-���----r------------- -------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS - ------------------------------------------------------------------------- - --------------------------------------------=---------------•----------- <br /> ------------------------------------------------------- ------------------------------------------------------------------ -------------------------------------------------------- <br /> --------------- <br /> -------------------------------------------------- ----------------------------------------------------------------------------------------------------------------- <br /> ` --- ------------------------------------------------ - <br /> Final Inspection by; •--------- ---------------- ------------Date_ °' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />