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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------------ <br /> (Complete in Triplicate) Permit No. <br /> --------------------------------------------------------- <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued <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 /> JOB ADDRESS/LOCATION ------Ad-/6/--.--) -------------=--- -- - CENSUS TRACT 0A------ ---------- <br /> - ---------------------------------- <br /> Owner's Name r0ll�.Lt-lr---------------- Phone - _ �- - <br /> Address /�.�'. f ------------ City --------------------------------------------------------- <br /> Contractor's Name ?'"' ---------------------------------------------------------------License # ------------------------ 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 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam] <br /> Hardpan2] 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 [ ] SEPTIC TANK [ ] Size----------------------------------------------_ Liquid Depth -------------------------- <br /> Capacity ------------- <br /> --__---__-----_--_---_-Ca acit .-____ Type -------------------- Material---------------------- No. Compartments - <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 ----------------- <br /> ------- Property Line ------------------------ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------- ------------ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------__ ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---•--- ------------------------------------ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------------------------- -------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ___ _- _- -- ----- ------ ---- --------------__- _- <br /> ----------- - -- -- -Q r '. ' -- ------ <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 <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature rtifies the following: <br /> "I certify that in following- <br /> .h <br /> rformance o the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become sub) �111orkma o n tion law o alifornia." <br /> Signed -------- . -- . ------... ----- - - - - -- --------------- Owner <br /> BY -------------------- - <br /> ------------------------------ - <br /> ---- ---------------------------- Title -------- ----------------------- ---------- --------- ---------------- <br /> - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------ZZ- ----- -�------------------------------------------------------. DATE --Y" "-.. )--------------------- <br /> BUILDING PERMIT ISSUED -------------------------------------------------- - ----------------------------------- <br /> ------------------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 />