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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. .�_�-��� <br /> ---------------------------------------------------------- (Complete in Triplicate) ----------- <br /> Date Issued �---`-��.-_�9 <br /> This Permit Expires 1 Year From 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 /> �/ R�-------- ----- -- - <br /> -----------CENSUS TRACT --------------a----------- <br /> JOB ADDRESS/LOCATION ��±-�- --- --- -- -------- ------------- <br /> Owner's Name --_- �-.-- -- r Phone <br /> - - ------ ------ - -- ------------------------------- - <br /> �--__ Cit <br /> Address Y <br /> Contractor's Name __- <br /> ----v License # ,� Phone <br /> Installation will serve: Residence Apartment House-E] Commercial ❑Trailer Court <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:---- Number of bedrooms _ ----_Garbage Grinder ------------ Lot Size ____. <br /> Water Supply: Public System and name --------------------- ---------- ------------------------------------------------------ ------.Loam Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat F] Sandy Loam Clay :[] <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 se age pit permitted if u�lic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTI TANK' ] Size_/;X-_-_�.1�___If.___-�_____-____ Liquid Depth -. - :----- <br /> Capacity Type __ ___ _ _ ______ Material---L°_c!yc��C�.e�lo. Compartments � p <br /> / r <br /> Distance to nearest: Well - _--------a------------------------Foundation ---- --4------------- Prop. Line --5-------_-------- <br /> LEACHING LINE No. of Lines ----14---------------- Length of each line------ I-____.__-__ Total Length - ---------------- . <br /> 'D' Box -- Type Filter Material ----- -----Depth Filter Material ------/_5F--------------------------- <br /> Distance t nearest: Well ------------------------ Foundation ________________________ Property Line ______________--------- <br /> SEEPAGE PIT Depth _____ Diameter ---------------- Number ____________________________ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth -------------------------------Rock Size ---------------------------- <br /> Distance <br /> ---- :-------------------- <br /> Distance to nearest: Well ------------------------- ------_Foundation -------------------- Prop. Line _.----------------- <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ___________-----------------------) <br /> Septic Tank (Specify Requirements) -------- -------- -------------------------------------:------------------------------------------•---- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------- ---------------------------------------------------------------------------------------------------- <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 . he performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to becom sub 'Ct to Workman's Compensation laws of California." <br /> Signed ------ - ------------ -- -- --------- --- ------------------------------------------ Owner , <br /> --------------------------- Title . <br /> ------------------- <br /> r If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> I APPLICATION ACCEPTED 6Y -------- -4 -- ------------------------------------------------ --- -- <br /> ----------- DATE -_.----------;V ------------- <br /> BUILDING PERMIT ISSUED ----- ------------------ - ----DATE - ---------------------------------------- <br /> - - -- ------- <br /> ADDITIONALCOMMENTS ----- ----------------------------------------------------------- -------------------- -------------- --------------------------- <br /> -------------- <br /> 3 --------- ------------------------------------- ------------------------------------------------------------------- -------------------------- ----------- <br /> — — — — <br /> --------- <br /> ----- <br /> --------------------------- <br /> Final Inspection by: ----- , Date . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> w <br /> E. H. 9 1-'68 Rev. 5M <br />