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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r� <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) Permit No: <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 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/LOC ON (0'/1 _ _ _ __ _____ ------------ ----- <br /> _ -- CENSUS TRACT _________________________ <br /> Owner's Name - -+ ------------------------------- ---- --- _ Phone <br /> Address --------&1.5-,------ -----ems--z- i- City -----6 14_0----- ------ <br /> Contractor's Name -------- ------- --- t'-_.License # ��� Phone <br /> Installation will serve: Residence ❑r Apartment House❑ Commercial []Trailer Court ❑ 4' ' j �-�s� <br /> Motel ❑Other ----------/--------------------------------- <br /> Number of living units:------ ___-_ Number of bedrooms Grinder ------------ Lot Size -------------------------------------------- <br /> Water Supply: <br /> _______-_____________,_________________WaterSupply: 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 /> (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 seep ge pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ Size _ '_�_�` __--____.___--_ Liquid Depth .- ----------------------- <br /> Capacity p_p d__ Type - _ Materi No. Compartments ......... <br /> Distance to near t: W 1 ____-__��__--__-_-_______--Foundation -----1A Prop. Line .__.. ............. <br /> r <br /> LEACHING LINE No. of Lines --------- _ __ ____ ____ Length of each line------ ___ Total Length ._-,/_b.4.__.__........_. 11 <br /> Type Filter Material ___________ __ p �? <. <br /> 'D' Box -_ � �=--.----Depth Filter Material _______1_f___..............._,--._-_--- <br /> Distance t nearest: Well __.-------4P ..__-__ Foundation ---------L tt__`__-___ Property Line ____ ............... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <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 /> DisposalField (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 /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becom s bject to Workman' ompensation laws of California." <br /> Signed r,:.,...._ <br /> --- ----- ------- ---- -------- ------------------------- - .o <br /> BY " - - -- - -------'"�`- °L= ------ Title ^� �L <br /> (If other than owner) V <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - - -------------------------------------------------------- DATE ----------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------- ------------------ -----DATE <br /> ADDITIONALCOMMENTS ----------------------------------------------------- ---------------------------------------------------------------------------------------------- -------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- <br /> - ---------- -- <br /> ------------------------------- --=------- <br /> - , <br /> Final Inspection by: ---- -------------------------------------------------- - -----------Datejf:- _---- �, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />