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FOR OFFICE USE: - <br />!' APPLICATION FOR SANITATION PERMIT y <br /> (Complete in Triplicate} <br /> Permit No. .��............ <br />........................................................ This Permit Expires 1 Year From Date Issued <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 /> .SOB ADDRESS/LOCATION ..-___.. _ .---.-•-____-- , <br /> -- •- -- •.............................CENSUS TRACT ................. <br /> ..._..... <br /> Owner's Name ........ ...... ... ....... ... ----------------------- ......... ..Phone ........._.... ..................... <br /> Address ...................%Zag G j <br /> - ---------- ................ <br /> City ................................ <br /> Contractor's Name ......License -......_..... <br /> #.--A Phone <br /> Installation will serve: Residence [t"Apartment House[] Commercial ❑Trailer Court <br /> Motel ❑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 ❑ <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 pefmitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ] Size................................................ Liquid Depth ....... .............. <br /> Capacity .................... Type --------------------- Material...................... No. Compartments <br /> Distance to nearest: Well ........:...........................Foundation ...................... Prop. Line ...................... <br /> LEACHING LINT: /No. <br /> No. of Lines <br /> ----------------- Length of each line----------------------------- Total Length ............................ <br /> 'D' Box .............Type Filter Material ....................Depth Filter Material ----------------------------................ <br /> Distance to nearest: Well .............. Foundation ... Property ~tine .:....::..........: 6 <br /> SEEPAGE PIT O Depth _ Diameter ................ Number ._.._..__......._ ...... Rock Filled Yes --,No.0 <br /> Water Table Depth .......................... ............. ........Rock Size ................ --......_••--- - ..:,.. . <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Dote ....... ] <br /> SepticTank (Specify Requirements) -------------•------.---------------- --------------•--o---------•---....._.... -........................................._- .------------- <br /> Disposal Field (S e ify Ruiremet-ts-} <br /> ---------------!�. • <br /> ----------- � -------- .. <br /> ------------------------------------ -- -------------------------- ------------------ ------------------............................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> 1 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 .................. ... ......_......... _...... . Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY p <br /> APPLICATION ACCEPTED BY ..____ - ........................... DATE _- '. .............. <br /> BUILDINGPERMIT ISSUED .............................................................................•-•••••••.....- ........ DATE ... ....................................... <br /> ADDITIONALCOMMENTS ..........................................-.............................................................................................. ..................... <br /> ----------------------------•...---••--•--------------------------------------------------...------------------------......__ <br /> .-----• <br /> ................................. . ti <br /> .................... ........••-••----••---••----•--------------.._....--••------••-------••-•---•--•............---•----••- .... _.....�............................ <br /> -•-..... <br /> ------------------ = - <br /> • -. .. <br /> F . <br /> anal inspection by: <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT { <br />