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- AOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> _s <br /> ----�-- -----------------------• Permit No.�- --_-�- - <br /> (Complete in Triplicate) <br /> --------- ---------------------------------- <br /> �.'�.- 7f <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 per to construct and install the work herein <br /> described. This application is made in compliance with <br /> 1County <br /> Ordinance No. 549 and existing Rules and Regulations: <br />` JOB ADDRESS/LOCATION ------ --- ----CENSUS TRACT <br /> 2"-�-_ <br /> I <br /> Owner's Name -------- ----- -- ------------------------------- Phone <br /> Address --------- ----------------- <br /> g...-- <br /> < - ------------------------ .. <br /> ------- <br /> Contractor's Name ��. . ., -'��,---=-------T---'---k-.- -,-.License ------------------- Phone ------------------------------ <br /> Installation will serve: :. Residence 2 partment House❑ Commercial ❑Trailer-Court.-i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---/-"-'---- Number of bedrooms -_------Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> •� <br /> Water Supply: Public System and name' - ----------------•--------•-•---------------------------------------------- ----------------- =- <br /> ---------Private.[R '. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ ' Peat 0 Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe '❑ Fill Material ------------ If yes, type ---------------------------- !1 <br /> L' <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse s'ide.) � ' <br /> NEW INSTALLATION: (No septic tank or ;�7 <br /> pit permitted if`public•sewer is available within 200 feet,) j <br /> PACKAGE TREATMENT [ SEPTIC TANK: Size------------------------------------------------- Liquid Depth __--y <br /> n/�-�_�f�, ,�rr s <br /> Capacity 14610----- ,._ TypeAIV d_/--- Material�N__C-NGfe-___ No. Compartments .........:.... <br /> - ---------------------Poon��on . - ---------------Lenoth ----�-h--�-------------•- + <br /> LEACHING LINE [+INo. of Lines _-- __—..Length-of each-line_._-_ <br /> -------- Tota! g - <br /> Distance to nearest: Well C� -�' Foundation p. Line --------_--- <br /> R' Box . ... Type Filter Material -.Depth Filter Material' ------- .rte'--.f <br /> -----------------...... " <br /> Distance to nearest: Well _=^= 7 --------- Foundation - ---------------------- Property Line --------.-___-.--=,...ZM <br /> SEEPAGE PIT [ ] Depth --------- -Diameter-s f --Number ---------------------- ----W Rock.Filled _Yes ❑ No IQ <br /> Water Table Depth ----------------------------------------- ----Rock Size -------------"I--------------- i <br /> c -----•. <br /> Distance to nearest: Well ------------------ •---------------- Foundation- -- ---------------------- Prop. Line --------- ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------_---------- ------------------------ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------•------ -------------------------- <br /> Disposal Field (Specify Requirements) --------- - - --------------------------------------------------------------------------------- ------ <br /> - --------------- <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 certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, I shall nor employ any person in such manner <br /> as to be ome subject to Workman's Co pens i.on law f California."��,l -- Owners <br /> Signed s <br /> - -- --------------- <br /> BY ------------------------------ Title----r-------------`-- ------------------------------------------------ <br /> (If other than owner) `"_J <br /> LA <br /> FOR"DE ARTMENT USE ONLY <br /> ...: ..- <br /> f APPLICATION ACCEPTED BY -- DATE7-`_ <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------_------- ----------------------- - --------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS ; ----- ------------------------- ---- .. - ----- -- --,'----------------------------------------------------- <br /> _ _. .. _. .. i ------------ <br /> ----------------------------- --------------------------------------------------------------------•- -------------------- --- ----------- <br /> F -------------------------------------------•--------------------------------------------•------------------ -------------- -------------------------------------------------------- ------------------------- <br /> Date .. ` ��1 <br /> ------------------------------------------------------------------------------------ <br /> Final Inspection by: ------ - • -,�-- - -- ---------------------- --- - ------- � - ------------------- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />