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R OFFICE USE: -. APPLICATION FOR SANITATION PERMIT <br /> - <br /> ------------------------------ Permit No. <br /> (Complete in Triplicate) <br /> ------------------------------------------ <br /> Date Issued <br /> -----_------------------_------_-_----------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Sa Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with Count rdinance No. 549 and existing Rules and Regulations: <br /> W-1 <br /> ------CENSUS TRACT -------------------------- <br /> JOB,ADDRESS/LOCATION ._ ��--—-----i ( -.---------- ---- ------------ <br /> Owner's Name ----------- - -------- ----- -- - --- Phone -------------------------------•---- <br /> ` //D 5 _ ' <br /> Address J=_ ___/` _ City = "`------------------------------------------------------- <br /> ---------- --------- ----------------- -- --- ------- / <br /> Contractor's NameF r -------.License # __13c2- Phone ------------------------------ <br /> Installation will serve: Residence ❑ Apartment House-E] Commercial ❑Trailer Court ;❑ <br /> Motel 0 Other ----------- �------------- <br /> Number of living units_____________ Number of bedrooms --=---Garbage Grinder _-" ___ Lot Size ...... <br /> - ------- <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'E] <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot'plan, <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,J <br /> � <br /> PACKAGE TREATMENT I ] SEPTIC TANK'[ Size_3_t_/(__i_/,A �J__-f________._ Liquid Depth ___�-------------------- <br /> u-L' `O <br /> Capacity 4-- - Type ---------------- -- Material----- -- No. Compartments �� ------------ <br /> Distance to nearest: Well -----------„5:G----------------Foundation /_10___r___ Prop. Line ____ --___-_________ <br /> f <br /> LEACHING LIFE- {rJ No. of Lines ________1______________ Length of each line---------5_��-----------Total Length ------S_._�!............ <br /> 'D' Box------- Type Filter Material ___�_R_____--.Depth Filter Material --_J`I-___f_�___._.___------------ <br /> ...- <br /> Distance to nearest: Well -------fid...._..... Foundation __._.__ .......... Line -___-r---------------- <br /> SEEPAGE PIT Depth ____________________ Diameter ________________ Number ____----- -----_ '_________ Rock Filled Yes ❑ No I❑ <br /> i/ Water Table Depth --------------------------------------- --------Rock Size -------------------------------- <br /> ;' Distance to nearest: Well ________________________________________Foundation ------ <br /> _ -------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ------____________________._.-----) <br /> SepticTank {Specify Requirements) ----------------- --- ---------------------------------------------------------- ------------------------------------------------ ---------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> `----------------- ------------------- ---- ----- --------------------------- --- -----=--------------------------------------------------------------------------------- ----------- <br /> (Draw existing and required addition on reverse side) <br /> j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> I 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 /> F <br /> Signed --------------------- Owner <br /> i By --- - - - -- ---- -- Cr "`� -, r Title _�� -tic h <br /> (If other than owner) <br />' <br /> TR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------------------------- DATE ------ E?_=. <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ---------------------------------------- - <br /> ADDITIONALCOMMENTS ---------- ------------------- --------------------------------------------------------------------------------- ---------------------------------- <br /> -------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------- <br /> i ----- --- -- --------------- ----- -------- -------------------------------------------------------------------------------------------------- <br /> k ------------------------------------ <br /> --- --- <br /> Inspection by. ` - - - ------ '�� -- --- ------------------------------- Date _. �----7 -------------- <br /> I S N JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 <br /> E. H. 9 1-'68 Rev. 5M <br />