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FOR OFFICE usE: APPLICATION FOR SANITATION PERMIT p c,� <br /> - ------- - ----------- ------- Permit No. <br /> (Complete in Triplicate) <br /> ---------- Q 7 Z <br /> 0 <br /> �._D <br /> _______---- This_Permit Expires t Year From Date Issued bate Issued �_. -.._ ______.. <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 04 <br /> -------------------------------------------------CENSUS TRACT _aYT <br /> Owner's Name ----- dpr� -------- ------------------------------------------ --------- -----.Phone ------------------- •--------------- <br /> Address --------------- --------------------------- -------__ City - -- -----------------------------------------------------••---------- <br /> Contractor's Name --------------------------------------------- ------------=--------License # ---------:-------------- Phone ----------------------------- <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other --------------------------------- ------ <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size __-_----_____________---_____________-..____ <br /> Water Supply: Public System and name .----1--------------------------------------------------------------------------------------------------------Private ❑ <br /> '.. Character-of.soil-to a depth of Veet:- —Sand'[]- Silt El- C4ay .❑ Peat❑'�_Sandy Loam []z=ClayrLaam:O .. <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,) V\ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f I Size-----_------------------------------------ ---- Liquid Depth ------ ------------- Q <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 ] 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 ti=------------------------.-I <br /> Septic Tank (Specify Requirements) ------------------- ----------------------------------------------------•---------------------- --------------------------- <br /> Disposal Field (Specif Requirements) ------- -"��, ' ^A ---------- ------- ------- <br /> r , <br /> ---- <br /> -------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existingand 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._'...... - ------ Owner <br /> ------------------------------ <br /> By ---------- -- --------------------------------------------------------==----- --- -------------------- Title ----------------------------------- -------- --------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- -- � -------------------------- ------------------------------------- DATE i�0=,2 7Y------....-------- <br /> BUILDING PERMIT ISSUED --------------------------------------------------------------_--------------------------- --------------DATE ----------------------- ----- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------ --------------------------------------------------------------- ----- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------- ------------------------------------------------------------------------=--------------------------------------------------------------- -------- <br /> ----------------- -------------- <br /> - = <br /> Final Inspection by: -- - --------------- ---- - -- -----------------------------------------Date �-- `-'---------- ---- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />