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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --- (Complete in Triplicate) Permit No. . -------------- <br /> ------ <br /> ---------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and instil#i: the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: - <br /> �r <br /> JOB ADDRESS/LOCA N �"{ t -------------- CENSUS TRACT �� (., <br /> �_---- a <br /> Owner's Name - -, ---- --- --- ------ - ------- -- -- - ------------�---------------=--- -------------.-Phone-----------------------­-1----•---- <br /> Address ----------------- <br /> -------------- ✓ a� j A� City ------- -- -- - �� -----•------ <br /> Contractor's Name ---.-��----- ------ •.License # _L-� _ _ Phone ------- ---------------------- <br /> ----- <br /> will serve: Residence d partment 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'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam T� Clay Loam ❑ <br /> Hardpan [❑ 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 f ] 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 ------._ ..-._- <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 <br /> Water Table Depth ------------------------------------------------ Size --------------------------_ <br /> -----------------------=------ ----- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------..-....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank JSpecify Requirements) `^ <br /> / - - <br /> Dis osal Field (Specify Requirements) ---- __� -- -- <br /> ------ <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. Nome 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 Workman's Compensation laws of California." <br /> Signed ----------------------------------------- -------------------- Owner <br /> By -------------- " Title pieu� ' --------------------------------- <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----. DATE S_-' - -"7/--------------- <br /> BUILDING PERMIT ISSUED ------+ --------------------------------------------- - ----DATE --------------------- <br /> --------------------- <br /> ADDITIONALCOMMENTS --------- ------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - ------------------------------------- - ------ -----------=-------- - ---- ----------------------------------------------------------------------- -- - <br /> Final Inspection by: Dated------------ f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b$ Rev. 5M <br />