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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - -----�--- ---�---�-� - .-._,..------ --------- Permit No. . �7 <br /> (Complete in Triplicate) ----------- <br /> _--_.-. ....... -_-__ This Permit Expires ! Year From Date Issued f1�r <br /> 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 . /*/Vit?? .- - - -- - -- /---------CENSUS TRACT ----------------- -------- <br /> Owner's Name --------------------------------------------------------------------------------------Phone <br /> Address --------------- -- ----------=------------------------------------------------- City _1��------------------------------------------------------- <br /> Contractor's Name ..--------------------- --------------------------------- --------License # ---------:----- -------- Phone ------------------------------ <br /> Installation will serve- Residence ❑ Apartment House❑ Commercial : Trailer Court ,❑ <br /> F Motel ❑Other <br /> Number of living units:----)------ Number of bedroomsi--------Garbage Grinder _. - Lot SizeZt_cn•G----------------------------_ <br /> Water Supply: Public System and name -------------------------------­­------ ----------------------- --------------------------------------Private [❑ <br /> Character of soil to a depth of 3 feet. Sand'El Silt❑ Clay .[] Peat❑ Sandy Loam ❑ Clay Loam,® <br /> Hardpan jk Adobe '(] Fill Material --. --- ---- If yes, type ---------------------------- <br /> (Plot Dlan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) O� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) t <br /> PACKAGE: TREATMENT [ ] SEPTIC TANK{ ] Size------------- ------------- ------ <br /> ..--------- Liquid Depth -------------------------- � F <br /> - <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' <br /> -----.----•------------_.-- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------- ----------------------- <br /> Distance to nearest: Well ---------------__-- Foundation <br /> --- ------------------------ Property Line ---------•--------•----- { <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 <br /> ---------------------------------Se tic Tank (Specify Requirements) , �- - <br /> Disposal Field (Specify Requirements) -----------------------------•----------------------------------------------------------------- -- -------------------- <br /> ----------------------------- ------------------------ --- ------------------------------------------- -------- -------------------------------------------------I--------------------------------------- <br /> -------------------------------------------- <br /> -- ---- -- -- ------------------ - -- -------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) i <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 ------ Owner <br /> BY / 14/- --------------- Title ---------------- <br /> 714- -- - <br /> (if other than owner) <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE .------------•----------------------------- <br /> ADDITIONAL COMMENTS - <br /> ---- ----------------------------------------------------------------------- --------------------------------------------------------------- ------------------------------------ ---------- <br /> ------------------------------------ <br /> -- - ------ -------- - - - - - - - - - - - - �---- - ------- - ------ <br /> ----------------- --------- ----- -- --- -- - <br /> Final Inspection by: _�" .. -- ------------- -- -----------------------------Date ---- - ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />