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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.. <br /> (Complete in Triplicate) <br /> --_---_---------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made <br /> in compliance 'ith County Ordin ce No. .549 and exeNSUS <br /> Rules and Regulations. <br /> Pp <br /> JOB ADDRESS/LOCA N .- - :----- - - - '-- ---- ------ TRACT ------------ -------- <br /> - <br /> Name .- - -------------------Phone - _W'd-'t�- <br /> - - ---------- - -------- -- <br /> --------------------------------------- <br /> Address ---- -- r �� ---------=------------------------------------------------- City ------------------------•------ <br /> Contractor's Name ------ -------- ------------------------------- ------------------=-------.License # ---------:-------------- Phone ------------------------_-- <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other s,. <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' 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,) _ J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size------------------------------------------------ Liquid Depth ---_------------------.----- 0 <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --- -----------.._.... <br /> � <br /> Distance to nearest: Well ___________________________________Foundation ---------------------- Prop. Line ---------------_._ _. <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line--------------:------------- Total Length ----------- ----______ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------.....:---- t n <br /> Distance to nearest: Well ------------------------ Foundation _________.----------­_ Property Line ____________-___---_-- V - <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter -----------_---- Number ---------------------------- Rock Filled Yes ❑ No . <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Q <br /> Distance to nearest: Well _______________________________________Foundation --------------- Prop. Line __________--___-__.___ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------..-..-------------.) <br /> Septic Tank (Specify Requirements) --------------- --------- - - - - ti -------------------------------------------­ <br /> -Disposal <br /> ------------------------. <br /> -Disposal Field ( ecify Requirements) �^..�Q � ---------------- -Y---- <br /> ---o --- _ s ---- - ---- <br /> - - <br /> - ---- - <br /> {Draw existing and required addition on reverse side} <br /> I hereby certify that 1 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 becQM bje to W�rkm 's C pensation laws of California." <br /> Signed' �}`'`�-r - - ------------------------------------- Owner <br /> BY -------- ---------------------------------------------------------------------------------------------- Title -------------- ------- --------------------------------- ------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ------------------------------------------------------------ DATE 7 ------------------ <br /> BUILDING PERMIT ISSUED --- -- ----------------------------=---------------------------- ------------------------=--------------DATE ------------------------------------------- <br /> -'COMMENTS ------------------------ ------------'-------------------------------------------------------------- ------------------------------ --------------------------- <br /> -----------------------------------------------------------------------------------.----------------------------------------------------------------------------------------------------------------------- <br /> ---------- ------------------------- ----------------- -_-------------------------- ------------------------- ------------ ---------------------------------- --------------- <br /> ---------------------------------------- <br /> -------------- r <br /> -------- ----- ------ --------------------------------------------------------- -------------------$7-14-.-P-7v <br /> -14-- -7 <br /> Final Inspection by: .---- - ^ --------- ---------------- ----------------------------Date <br />' SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> E. H. 9 1-'68 Rev. 5M 'f <br />