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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------------------- 'U = <br /> (Complete in Triplicate) Permit No. _'7 <br /> v <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> --------------------------------------------------------- <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 <br /> County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO TION l_ _ __ ------ce - ' ------------------------------------------------------' CENSUS TRACT __---_____--..._____•. <br /> Owner's Name --- -- - - ---------------- ---- --- --- -Pho ----- ---------------------­- <br /> Address -_ - Cit ,��+� <br /> Contractor's Name ------------------ ------.License # -------- ------------- Pho a -----------------------_---_ <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units_____________ Number of bedrooms __-______-_-Garbage Grinder ------------ Lot Size _-______---•_-__________---__-___---__-_•__• <br /> Water Supply: Public System and name _____-0`�---(1141ve-&-____--�65e---c_--_-______--_____________________-.-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 /> (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 [ ] Size------------------------------------------------ Liquid Depth _-___-__-_•.____-.____-_•- <br /> Capacity -------------------- Type -------------------- Material----- -_ <br /> ---------------- No. Compartments .--- ..--------•-•--- .) <br /> 00 <br /> Distance to nearest: Well <br /> ------------------------------------Foundation _.--------------------.Prop..Line --------------------- 00LEACHING LINE [ ] No. of Lines _________ Length of each line---------------------------- Total Length ,_______________________•-_. IN <br /> 'D' Box ___________ Type Filter Material __________________Depth Filter Material __-__________•___-___-______-_____-.-•---. <br /> Distance to nearest: Well -----------------------. Foundation ------------------------ Property Line ........................ fT) <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No I❑ <br /> Water Table Depth --------- --------------------------------------Rock Size --------------------------_----- <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) ----- (: ----------- 7� /� . <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 not employ any person in such manner <br /> as to become subject to WArkrina,o Compensation laws of California." <br /> Signed r � -------------------- Owner <br /> BY - ------- ----- -- ------------------------ - ------------------------------------------ Title --------- - -------------------------------------------------- <br /> (If othe than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------- DATE _ /,� ' j �`� ----------------- <br /> -------------------------------- <br /> ----- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------•- -------------------------------------------DATE ---------------------------------•-----•--- <br /> ADDITIONALCOMMENTS --------- ---------------------------------------------------------------------------------------------------------------=-------_----------------- <br /> ----------------------------------------------- -------------------------------------------------------- ----------------------------------------------------------------------------- -------------- <br /> -- --------------------------------------------------------------------------------------------------------------- ----------------------. <br /> -------------------- <br /> Final Inspection by: ---- -- ------:' .s. r `"-----------------------------------------•-----------------------------------•---Date//.`----- �--------------•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />