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' FOR OFFICE USE: ' <br /> APPLICATION"FOR SANITATION PERMIT <br /> ----------------------------------------------- -------- <br /> (Complete in Triplicate) Permit No. <br /> � - - <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/LOCATION . �/ --- --------------- ------------------CENSUS TRACT ----------------------------- <br /> Owner's Name//- p�7-+-- ----- ------Phone RT <br /> Address ------- City <br /> Contractor's Name - ��% License # A!;Y �----- Phonel/=�� <br /> Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- _ . <br /> Number of living units:________ Number of bedroom __s?-._.Garba a Grinder ------------ Lot Size __ _ �_.___..____-.--- <br /> Water Supply: Public System and name _ -2 -- ----------------------------------------Private El <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 <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____________________ quid Depth ---.______•----_______ <br /> Capacity ------------------ Type -------------------- Material---------------------- No. Compartments ....... .............. <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 Line ______________-----._. <br /> SEEPAGE PIT [ J 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) ----------------- <br /> ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------.------------------------ <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 /> "I 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 beco su ject to, rk n's Comp ion laws of California." <br /> Signed R ------------ --- Owner <br /> BY ------------------------------- - ---, -- ----------------- Title ----------------------------- ---------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -f "- = ----- -------------------------------------------------- DATE �- �I <br /> ---------------- <br /> BUILDING PERMIT ISSUED ---- -------------=--- ------- -------------------------------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS ------------------- ---------------------------------------------------------------------------------------------------------------=---------------- ---------- <br /> -------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- ------------------ <br /> -------------------------------------------------- ------ --------------------------------------------------------------------------------------------------------------------------------- <br /> // --------------------------------- __ <br /> Final Inspection b _ _ 3t'__ �' <br /> j <br /> pY " ✓ ---- ------------------------------------------------- --------------- Date l�^l----- -------------------- <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />