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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------------------- -------------------- (Complete in Triplicate) Permit No.._ ----------------------- --------------------------------- Date Issued______-___________ ___________________________-____________________.___.__ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and 'install the work herein described. This application is made in compliance with County Ordinance No. 9 and existing Rules and Regulations: JOB ADDRESS/LOCATION------ -.-----------------------------------------CENSUS TRACT--------------------------------- -------------------------------------- Owner's Name--- ------�� -----------------------------------------------------------------Phone Address--------- --- - --- ------------- -- - ----------- --- ----------------City------------------ ------ --�J/ -----Zip---►-------- ------ Contractor's Name--------- � f-��------__--------License # ��C� < !_!--_--Phone-- 1---��-© 4 -0c �� Installation will serve: Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ s Motel ❑ Other----------------------------- __ x Number of living units:--._--/-------Number of bedr o/m��s---___Garbage Grinder------------Lot Size--------- -D-__.__.________-__ 1-1 f Water Supply: Public System and name----- -------`---��------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe❑ Fill Material------------If yes,type------------------------..______ S (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW -INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feed - PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-------------------------------------------------------__-.____Liquid Depth--------------.___-_--____ Capacity---------------------Type--------------------._Material------------- --------No. Compartments=----=------------------------- Distance to nearest: Well--- ---------------------------------------Foundation--------------------------Prop. Line_______-_-_____--__-__-_. LEACHING LINE [ ] No. of Lines-----------------------------Length of each line.------------------------------Total Length._ 'D' Box------------Type Filter Material--------------------Depth Filter Material______________________-___--_--___________-___-_________-__. Distance to nearest: Well----------------------------Foundation----------------------------Property Line_________---.--_________._____- , SEEPAGE PIT ( ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ WaterTable Depth---- ----------------------------------------------- ----Rock Size----- ------------------------------------------ Distance to nearest: Well____________________ -________Foundation_________________.-__-.Prop. Lin _v____._______________- REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------------ __.__. ate- _-______--.__ _ _ _______-__ _-__-___},� Septic Tank (Specify Requirements)------ -- ------------- ---------- -- ------- -- - ----- - - - Disposal Field (Specify Requirements)---R__--�A----1/� T �`�''� F ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- - - ------- ------------------- -- - ---- -- --------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed - ---------- --- ----- - ------ - -----------Owner BYTitle r (If other than ownef) fOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY------- / -- - - ------------------------------------------ --------------------DATE ----- DIVISION OF LAND NUMBER -- -------------- - ---- s -------------------------- DATE-------�/_ ----- - --------------------------------- -------------------------- ADDITIONAL COMMENTS---------------- Q K- _?J<--------------- ---------------------------------------------------------------------- ----------------------------------------- ----- ------ -------------- --------- --------------------------------------------------------------------------------------- -------- ------ ----------- ---------- --------------- ------------------------------- ---- ------ --- -------------------------------------------------------------------------- --------- J Final Inspection bY:---------------- - ---- - -----�------- -------------------------------------------------------------------------- __Date------1' l 7� ---- ------_3 EH 13 2a SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 2x�n Rev. �nb 3M