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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �s_�� <br /> -------------------------------------------------- <br /> (Complete in Triplicate) Permit No_ _________________ <br /> ------ -------------------- --------------------- This Permit Expires 1 Year From Date Issued Date Issued = 31� <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 Coou ty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ " _ — ---- ----------------CENSUS TRACT -------------------------- <br /> -------------------- <br /> Owner's Name = - --- ----- -- -------------------- --------------- Phone <br /> Address ---- --------- - -- - -------- City <br /> - -------------- <br /> -------------------------------- <br /> Q <br /> Contractor's Name ----- --- - --------- -- - - <br /> -- --- -1 icense # /�� �3� Phone ------------------------------ <br /> Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other --- ------- ------------- <br /> Number of living units:...1----- Number of bedrooms __/----_-Garbage Grinder ------------ Lot Size -. - <br /> ----- <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 /> Hardpan -Adobe-❑ Fill Moterial ------------ If yes, type --------------_------------- <br /> (Plot <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 -------------------- Type -------------------- Material---------------------- No. Compartments ------ ---•-------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ---------------------------- N <br /> 'D' Box ------------ Type f=ilter Material --------------------Depth Filter Material _____________.______.___________--___.______ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------.--._ <br /> SEEPAGE PIT [ ) Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes No C] <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line _____---__--____-_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------------------------------------- -------------- ----- -- -- <br /> _------------ ----- --- <br /> Disposal Field (Specify Regyirements) -------0_416 --- - ' - -y ----- -------------------------------- <br /> ----------------------x ----- ------- ---------"--"----------- <br /> --------------------- --------------- --- ---------------------- ------------ <br /> -------------------------------------------------------------- ---- ------------"--------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 lett to Workman's Compensation laws of California.” <br /> Signed --- -- -- --------- --- ---- ---- ----- -------------------------------------------- Owner <br /> BY -�----- ----- ------ --- -- - --------------------- Title -----�f� . =----------- <br /> ------------------------ <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ---------------------------------------------------------. DATE - --7-- 7ZZ-•------------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------- - ---- --- - -- ---------I----DATE ---- -------------------------------------- <br /> ADDITIONAL <br /> ------------------ -- ------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --- --------------------------- ------------------------------------------------------- <br /> ---------------------------------- - - - --------•---------- - ---------------------- --------------------------------------------------------- / ------ <br /> �JFinal Inspection by; - -- - - - ---------------•--•------•-•--•----•----------------- •-----•--••--•---._.Date . ..-•- --•7•�--------•-•- ..... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />