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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No: .�.-�__�,�� <br /> _ (Complete in Triplicate) <br /> ----- -- ------------------------------- - <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> E 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 Co my Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC 10J ---..----------- -- ------- -- ---------------CENSUS TRACT ---------------------._... <br /> Owner's Name ------ - -`'"- - ---- l�# -~�,J -- ------ Phone <br /> Address ------ ------------ d ---city ' <br /> �, rG <br /> Contractor's Name .= ------.License Phone <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court i❑ <br /> Motel [7] Other - 1 ----------------------------------- <br /> Number of living units:------ Number of bedrooms -----------Garbage Grinder Lot Size ___ -_�'-_--- ______________________ <br /> Water Supply: Public System and name ------------------------=- ------= = _ =_._—__-----------------------------------------------Private ❑ "�" <br /> Character of soil to a depth of 3 feet: Sand'❑ Sift❑ 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 /> INSTALLATION:NEW (No septic �eepa e p't"per 5 �d public`ewe_r� ailable within 200 feet, <br /> SEPTIC TANK � - -----------PACKAGEREA7MEN7 Zf 0� <br /> Liquid Depth ----______________,__.. D <br /> Capacity __�_d�`�'�'_ e _ _ _______________ Material40-1^- _------ No. Compartments ____ ...._.__.. <br /> � � Foundation <br /> r <br /> �istance to nearest: ell ____.____.__�C2______________Found'atlOn ------1__Q__------ Prop. line ___- ________ <br /> [ -3-._-_ --_-_ Length of each line-----��_�r_---------. Total Length :_ -------------- <br /> LEACHfNG LINE No. of lines --_____ <br /> 'D' Box _ ._ ._ Type Filter Material f---- _�R_.___Depth Filter Material -----tt_5------------- _,__------ <br /> ... <br /> Distance t ea rest: Well ------ --------- Foundation Foundation _____ ---------- Property Line ---------.---__----_.-._ <br /> SEEPAGE PIT [ ] Depth -.--_.____._______ Diameter_--_-_ --- Number ---------i------------------ Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size - ------------------------------ <br /> Distance to nearest: Well ---_-- - --------- _ _ ____Founclati'on ------------ ------- Prop. Line -._-_-_---_-__-._ <br /> I REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ Date __________-_______--_____________-I <br /> SepticTank (Specify Requirements) ------------------------- ----------------------------------------•----------.-------------- ---.----------------------------- <br /> Disposal Field (Specify Requirements) ------------- --------------------------- ---------=------------------------------ <br /> -------------------------------------------------------------------------------------------- ----------------------------------------------------------------- <br /> --- ------------------------ ------------:----------------------------------------------------------- <br /> kt (Draw existing and required addition'on'reverse side)', <br /> f 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 <br /> APPLICATION ACCEPTED .BY __ ---. DATES f- r �_____ _________ <br /> ------------ --- --- ----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------- - --------------=--------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------------ ------------------------------- <br /> ----------------------------------------- -------------------------- ------------------- ------------------ ---- ------------------------------------- <br /> Final Inspection by: --- ------------------- --------------------------------- ---------------- Date -c�- ------ <br /> SAN <br /> -SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />