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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---- ----------------------------- ---------- <br /> (Complete in Triplicate) Permit No. <br /> ----------- ---------------------_-----------------_-. This Permit Expires ] Year From date issued 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 .--------V' 010--------4q-S 5c=--- _ CENSUS TRACT <br /> Owner's Name P4.hl-. Q - �' - Phone -------- -------------- ---------- <br /> Address ------•--• City /--------------------- ----------------_----- <br /> Contractor's Name --- ----- r iLt/-/CJS ------.License # ---------.---- y`�� �f <br /> Phone �7 <br /> Installation will serve: Residence T<partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units: ----- Number f bedrooms �--_-...Garbage Grinder ---- of Size ..-_}___ ------------------------- <br /> - <br /> ---Private <br /> Water Supply: Public System and name `± � 0 <br /> Character of soil to a depth of 3.feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy. Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ill 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,) Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size. ---_�r...l...------.-- Liquid Depth ..... <br /> --------------- <br /> Capacity <br /> _.------Capacity ..1_'2Q-o------ Type -PKE Material---------------------- No. Compartments --._--_--__ <br /> Distance to nearest: Well ------------------------------------Foundatif n .../pl ------------- Prop. Line ----_--- ----------- <br /> LEACHING LINE [ ]l No. of Lines �------------------ Length of each line--_._ -------.--------- Total Length .�6.--......___.._ <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 C <br /> Water Table Depth ---------------------------------•--------------Rock Size ----------- ---------------_--- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -•-------_------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -.......__..-..--..-.__.._.._...--) <br /> SepticTank (Specify Requirements) ------------------- ----------- --------------------------------------------------•---------------------------.----------------------------- <br /> DisposalField (Specify Requirements) -------------------------- •--------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_------------------------ <br />' ---------------------------- -------------------------------------------------------------------------------------------- ----------------- ------------------­­­----------------- <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 Owner <br /> By - --- - - Title --- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BYAE DATE ..._f 0- _(�­�-1 <br /> BUILDING PERMIT ISSUED - ---------------- -- -- ------DATE -------------------------------- -- <br /> ADDITIONALCOMMENTS ----------------------------------------------------•------ ----------------------------------------------------------------------------------- ------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------• - <br /> -------------------------------------- <br /> e ------- <br /> ------- <br /> , - atrFinal Inspection by ---------- vL +_ D � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT e) <br /> E. H. 9 1-'613 Rev. 5M <br />