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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - - - - - -- ------ <br /> --•--------------------- Permit No. --- -- - --- <br /> ,' �3t) (Complete in Triplicate) <br /> -- ------ -------- ----------- ��- <br /> `.-�------ This Permit Expires 1 Year From Date Issued Date Issued ..................T <br /> Application is hereby made the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application made in compliance with County Ordinance No. 549 and existing ules and Regulations: <br /> JOB ADDRESS/LOCATION ��-----_.---- _l--_ 7-s—e----- -CENSUS TRACT ___ ________________ <br /> Owner's Name ? �q -------- c'C� l'`� - _ ---Phone _ h-1 . -- <br /> � ----------------- Cit,Address <br /> ` <br /> ' _ �' - ------------------------- ' (� = {� <br /> Contractor's Name ___ ._ e___-__ ( _ __ �/ ` License # -�T� -YPhone _ <br /> Installation will serve: Residence ❑Apartment House❑ Co mercial [-]Trailer Court i❑ <br /> Motel ❑ Other __ 2�- :. <br /> Number of living units:__--j-___ Number of bedrooms __--..._.Garbage Grinder ------------ Lot Size --------------------------------------- <br /> Water <br /> :____-__-- __-_-.'_________________Water Supply: 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> L <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ J Size----- - 4._r�__ Liquid Depth _yam,---------- <br /> .. <br /> Capacity / __)-6_,__ Type �(_n Compartments � <br /> Material_ ati�' :'�-'i No. Ctt ---------=----- <br /> Distance to nearest: Well ------- '___t-............Foundation --- .�'___/-__-_-_. Prop. Line -_,�'......:.......:,J <br /> LEACHING LINE [ ] No. of Lines ----- Length ______________ <br /> _____��__________ Length of each ,line-_�_� _____-_____ Total Len _,�.i_t� � <br /> 'D' Box ---�_------ Type Filter Material _��-------------Depth Filter Material _ --------------------------------------O <br /> Distance to nearest: Well ___ -- ____-_. Foundation -.--- Property Line C f/......_.---•_ <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) ---- ------------------------------------------------------------------------- -------- -------------------------------I <br /> DisposalField (Specify Requirements) ----------------------------•-------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ <br /> ----------------------------I-----------------------------------------------------------------------------------------------•-------------------------------------------------------------------------- <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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------ - -�'l ---------------- Owner <br /> --- ------------ -------- -------------------- <br /> By --------------- C `= --------------- Title ------------------------------------------------------- ---------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY 1 <br /> APPLICATION ACCEPTED BY -- ----------------------------------------------------- A <br /> ----------- <br /> _____________ DATE _---__ _— <br /> BUILDING PERMIT ISSUED --- ---------------------------- --------------- - - -------------------------------- <br /> --------------DATE ------- ------------------------ <br /> ADDITIONALCOMMENTS --------------------------------- ------------------------- -----------------------------------------------------------------------=------------------- ...... <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------- -- --- ------- _ <br /> --------------------------------------------------------------------------------------------------------- ---- <br /> FinalInspection by: ---------------------------•----------------------•---------------------------------------Date -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />