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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------------------------------- ----------I----------------------------------------a (Complete in Triplicate) - Permit No_ _____________________ _____-_________----- This Permit Expires 1 Year From Date Issued Date Issued __ ________________ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION .---------------------------------------------------- ---------------------------------------------------CENSUS TRACT -------------- ----------- Owner's Name ------- ------------ ---------------------------------------------------------------------------------------• ------------------Phone ------------------------------------ Address ----------------------------------------------------- ------------------------------------------------- City ---------------------------------------------------------------------------- Contractor's Name ------------ --------- ---------------License # -------- --------------- Phone ------------------ Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number of living units:------------ Number of bedrooms ____-_____-Garbage Grinder ________-.-. Lot Size -----______________________________________ Water Supply: Public System and name -------------------------------------------------------------------------------------------------- ------ -----Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan E] Adobe-❑ Fill Material ------------ If yes, type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth ____._-___-.-____-_ ------- Capacity -------------------- Type -------------------- Material----------------------- No. Compartments -----------.........; Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line __.----.------------7_ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length _________________________C t 'D' Box ------------ Type Filter Material --------------_____Depth Filter Material --------------------._--____--__-____-___-__ Distance to nearest: Well ------------------------ Foundation ________________________ Property Line. _______________ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ____________________________ Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ------------------------------•- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date --------.-------.-.-____________-_} Septic Tank (Specify Requirements) ------------------- --------------------------------•----------------------------------------------------- Disposal Field (Specify Requirements) -------------------------------------------------------------------------------------------------------- ----------- --------------I-----------------------------------------------:-------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side} I hereby certify that I have prepared this application and that the work will -be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Jo6gU'n..Local Health District, Home owner or licen- sed agents signature certifies the following: t "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -------------------------------------------------------- ---------------------- Owner By ------------------------------------------------------------- --- --- --------------- Title -------------------------------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ------- - DATE _________________________ ----------------------------------------- -------- ------ --------- --- - ------------------ BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------------=--------------DATE - - --------------------------- ADDITIONALCOMMENTS ------------------------- ------------------------------------------------------------- ------------------------------------------- --------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FinalInspection by- ------------------------------------------------ --------------------------------------- ----------------------------.Date -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT z E. H. 9 1-'6$ Rev. 5M