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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / <br />------------------------------------ <br /> ------------------- <br /> -� (Complete in Triplicate) Permit No: <br />------------------ ------ --------------------------- <br /> Date Issued <br />- <br /> -------------------------------------------------------- This,Permit Expires 1 Year From Date Issued <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI __,3•�___�__ 1 -------------------------------CENSUS TRACT --------------._--__--._.- <br /> ------------------Phone <br /> Owner's Name ------------ ------ -------- --- --------------------------------------- ------------------- ------- <br /> Address -------------- �✓ ---------- --� ----- -- ------------• . City __ �- ---------------------------•-----•--•------ <br /> -----..License# 1 �' Phone ------------------------------ <br /> Contractor's Name .-- - _ - )r 11`= <br /> 11 -------- -------- �' <br /> Installation will serve: Residen Apartment House❑ Commercial [Trailer Court ❑ <br /> Motel ❑Other-------------------------------------------- <br /> Number of living units:-----1----- Number of bedrooms ______Garbage Grinder ___________ Lot Size _______________•_.-____--.--______--------- <br /> el <br /> Water Supply: Public System and name ------------ --- ------------ - - -- -------------------- ------Private 1771Character 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 [ I SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -----------_-----,---.-•--• <br /> Capacity -------------------- Type ------ Material---------------------- No. Compartments ---------------------- <br /> Distance <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 Lime. --------- ------------ <br /> SEEPAGE PIT [ ) Depth ___________________ Diameter ---------------- Number .--------------------------- Rock Filled Yes ❑ No ,0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----._________•--__-_____--.-----_) <br /> SepticTank (Specify Requirements) ---------------------------------------------------- ---------- ------------------- ---------------------------,.--------------------------- <br /> Disposal Field (Specify Requirements) _____ 'Tc'-- -- -------- --------- <br /> ,.�p" r —' `-r>w=-i? l ,:, ----c�`---------3--- .',1� �`' ' <br /> J � i� <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. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which#his permit is issued, I shall not employ any porson in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------------------- - -------- -------------------- Owner <br /> z` Title _-- Q�w� <br /> BY - - - ----- �`'' ` <br /> (If other than owner) <br /> FOR DEPMTMMT USE ONLY <br /> APPLICATION ACCEPTED BY ___` DATE __��_` 7d__________-____ <br /> ----------------------------------------------------- <br /> BUILDINGPERMIT ISSUED -----------------------------------------------------------------------------------------=--------------DATE ---------------------------------•---- <br /> ADDITIONALCOMMENTS ------------------------------------------------------- -------------------------------------------------------------------------- -------------- - <br /> --------------------------------------------------------- ------------------------------------------------------------------------------------ ----------------- ------------ <br /> ------------------------------------------------------------------------------------------------------------ <br /> ----------------------------1111-- - ----- --------------------------------------------------------------------------------------1111-- - <br /> Final Inspection by: _ � —�Q <br /> -- -��-�- --- - --- - -------------•--------------------------------------------------1111---.Date ---------------------------1111-- -1111-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />