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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT f \ <br /> ---------------- -- -------------------- Permit No. -- I�1�� <br /> (Complete in Triplicate) <br /> _____________ _____ `This Permit Expires I Year From'DateIssued <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 /> t . - <br /> JOB ADDRESS/LOCATION .---'-M------------------------------------- ---------------------- ------ --------------_----- .-CENSUS TRACT <br /> Owner's Name ------- --------------------------------------- ------------------------------- --------- - -Phone <br /> Address ----------------------------------------------------- ------ ------------------------------------------ City ------- -------------------------------------------------------------------- <br /> Contractor's Name ---------------------------------------------------------------License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court Ll <br /> Motel ❑ Other ---------------------------------;. -t <br /> Number of living units____ _ Number of bedrooms ------------Garbage Grinder"--- ---I--- Lot Size ____-_-___-_-_---------____--_-_---_-- <br /> Water Supply: Public System and name -------------------------------•-•----------------------------------------•-----------------------------------•Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'o 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 permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK'f J -:0-Size--------------------------------------- Liquid Depth ------_-_-_--____-__--___ <br /> Capacity -------------------- Type ----- -------------- Material----------------------- No. , Compartments ---------------------- <br /> Distance to nearest: Well ____________________________________Foundation ---------------- Prop.Prop. Line _-_----_---__--_-__--_ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of -each line---------------------------- Total Length ---------------------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------..-.-._---... <br /> 1 <br /> Distance to nearest: Well -.._.---_---_--_-----_ Foundation ------------------------ Property Line _-----_-----_---_---_-- <br /> SEEPAGE PIT [ ] '56pth -------------------- Diameter ----------------- Number ------ - Rock Filled Yes ❑ No 1❑ <br /> Water Table Depth -----------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ----.--------------- Prop. Line -_-------------------. <br /> ..y <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _______ fir-------------------------- Date _______________--_--__---_----__--} <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------•------------------------ ---------------- -------- <br /> DisposalField (Specify Requirements) ---------- -------------------------------- ----------------------------------------------------------------------------- <br /> ------------------------------ --------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------ <br /> ---------•-------- <br /> --------------------------------- - -- ------_ = -----------------------------------------­­------------------- ---- <br /> d {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 f <br /> County Ordinances, State Laws, and Rules and Regulations ofthe San Joaquin Local`Health District. Home owner or licen- <br /> sed agents signature certifies the following: i ° ' -, -- " A <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 ----------------------------------- -----------------=---------------- <br /> Owner <br /> Y _ _ <br /> BY -------------- -------------- _-.�.__�---Y-- ----- -------------- == ----------------------- Title ---------- ---------------------- - <br /> ---------------------------- <br /> (If other than owner) <br /> ' -FOR YDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .------ ---' ------------------------------------------------------------------------------ DATE <br /> BUILDING PERMIT ISSUED -----------------i----------------------------------- ------------- ---- ---- <br /> -----------------------------DATE <br /> - - <br /> ADDITIONAL COMMENTS -------------------------------- - -- — -- _ <br /> ---- _ . _._ ._. <br /> _. <br /> -------------------------------------------- <br /> t w.• .- <br /> _.----------'- ---- t <br /> _-----------------------------------------------------------------------------------------------------------------------------------—-----—---------------------------------------------------=-—---- <br /> FinalInspection by: -------------------- -----------------------------------------------------------------------------------------------Date ----------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />