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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Ip <br /> -----=------------- -- -------- Permit No: --------~------1----. <br /> (Complete in Triplicate) <br /> --------------------- ----- - <br /> Date Issued <br /> . ____ __________________ -------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 -----• ---- -- -CENSUS TRACT ----- - k-.--.-.--- <br /> Owner's Name t----------------------------------------' -- <br /> --------- -------Phone ----------------------------.-------- <br /> Address - " t <br /> A/ ----------------- <br /> Contractor's Name ------------------------ ------------------------------.License # --------- -------------- Phone ------------------_---------- <br /> Installation will serve: Residence ❑ Apartment House-[] Commercial :❑TrailerLetfft , <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 /> Hardpan [? Adobe ❑ Fill Material ------------ If yes, type -____-_-------------------- <br /> Li <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NN <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK 1] Size-��ya'_--O---. - ---�---- <br /> ------------ Liquid Depth �--�----------- -_-- <br /> Capacity I2-0-V------ Type Material_ a?•,r ------- No. Compartments <br /> Distance to nearest: Well _- -------------------------Foundation _/b_-__--____-___ Prop. Line -.S"-_--_--__-______- <br /> LEACHING LINE +] No. of Lines ----X---------------- Length of each line---CO----------------- Total Length ____.._..----____ <br /> f` 'D' Box Type Filter Material 1.2)f�_---_---.Depth Filter Material ______________________ <br /> E --------------- Property Line _eC----------------- <br /> Distance to nearest. Well _--s)--�-------------- Foundation --/V <br /> SEEPAGE PIT [¢] Depth -- - ._----_ Diameter -2-3w------ Number -------3-------------------- Rock Filled Yes rj] No I❑ <br /> Water Table Depth ----6.4 ----------------------------------Rock Size -�"--------• <br /> 1 <br /> Distance to nearest: Well /4-.----------------------------Foundation ----14---------- Prop. Line $.,................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------._----_---.-._--___-__-_.-_} <br /> ' Septic Tank (Specify Requirements) ------------ --------------------------------------------------------- -------•------------------------------I------------ --------------- <br /> Disposal <br /> ---------:-------------- --.---------------------------- <br /> Disposal Field {Specify Requirements) --------------- ----------------------------------------------------------------------------------------------------- --------------- t <br /> ------- ------------ --------- - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> �f. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son 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 /> j "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 beco a bject t orkm 's Compensation laws of California." <br /> Signed ----- - Owner <br /> By --------------------- ----- ------ Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> f, <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY pt <fi --------------------------------- ------------ DATE - --_ 3'7 .-•---------------- <br /> ' BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------"-------- -------DATE ------------------------------------------- r <br /> ADDITIONALCOMMENTS ------------------------------------ ----------------------•------------------------------------------------------------------------------ ----- ------------ <br /> ------ - - - _- <br /> ---- -------------------------- ---------------------------------------------------------- ----------------------------- --------- <br /> -- --- ----- <br /> ---- -- - <br /> --------------- =------- - ------- -- --------------------------- ----------------------------------------------- ----------- f <br /> - - I <br /> Final Inspection by ------------------------ ----------.Date ' ._ . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />