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FOR OFFICE USE: <br /> APPLICATION FOR SANITATI6A PERMIT <br /> ----------- -------------- ---- Permit No. <br /> ---------- <br /> (Complete in Triplicate) <br /> --------------------- ----:------------ This Permit Expires 1 Year From Date Issued Daie ]ssued ._- <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 . /7/Y:3 ---.CENSUS TRACT __________ ____________ <br /> Owner's Name _ -------Phone �� T' <br /> Address -------1-/LI o � <br /> City -------------------------------•---••--- <br /> � � <br /> Contractor's Name � ___ -��.License # �lJ � - ------- Phone ---------------------------•-- <br /> c�A artment House° CommerciaInstallation will serve: Reside l ❑Trailer Court i❑ <br /> Motel ❑ Other ------- -------------------------- --------- <br /> Number of living units:-------l--- Number of bedrooms ---3----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 /> Hardpan [] Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> � V <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 /> i <br /> Capacity ------ -- --- ------ Type -------- ----------- Material---------------------- No. Compartments ---------------------- 1 <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> T11%, <br /> LEACHING <br /> --------- :_.------ <br /> LEACHING LINE { ] No. of Lines ------------------ Length of each line.--------------------.------ Total Length ------•----•---------------- � <br /> D'. Box---------- Type Filter Material --------------------Depth Filter Material ---------------------•----------.-----•...... <br /> Distance toinearest: Well ------------ ----------- Foundation ------------------------ Property' Line _-______-_-__--_________ <br /> -__ Number ------------------- -- --- Rock Filled Yes No '0 <br /> SEEPAGE PIT [ ] '�Depth ____--'_____________ Diameter ___- __-__- - - ❑ <br /> . _ . <br /> .-Water Tablee _ <br /> Depth -_..----------_-- _-.--------------------•---------..Rock Size -------------------------------- <br /> Distance <br /> ----------- - -------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ------------------- Prop. Line ---•------------------ <br /> -REPAIR/ADDITION(Prev, Sonitotian.Perm it# ---- ----------------------------------- -- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------- ---- ----------------------------f---------------------------- ------------------------------------ -----------------••• ; <br /> Disposal Field (Specify Requirements) ---- ------ - ----------- ------------------- ----- ------- <br /> ------------- Q_� ------z-'cP P - <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 Iicen- i <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 Workman's Compensation laws of California." <br /> Signed -------------------------------------- Owner k <br /> ---- ------ -- <br /> -- ---- - --- <br /> - --- - Title <br /> By --------- --- <br /> - -------------------------------- <br /> t <br /> - <br /> (lf other than owner) ' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .../ - i ------------------- <br /> ------------------ ------------------ --• <br /> DATE ., " �+ 7. ------------------- <br /> --- ------ --- <br /> BUILDING PERMIT ISSUED ---------------------- -------------------------- -- <br /> ---------------------- ----------------- ----- ---DATE ------ --------------------------------- <br /> ADDITIONALCOMMENTS ----------- ------------------------------------------------------------------- --------------------------- -----=--------------------------•-•---------------- <br /> ------- ---- - -------------- =------------------------------------------- -------------------------------------- --------------------------------------------------------------- ------------- <br /> - ---------------------------------------- ----- -------------------------------- <br /> - ---- - -------- ------ _ tt <br /> Final Inspection by: --_-----------------=---------=------------=--==-=--_=---------------=--==---Date -: --71__ <br /> SAN JOAQUIN LOCAL HEALTH-' DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />