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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---•.................................:.........•--••- •-• Permit No. ....7............... <br /> (Complete in Triplicate) <br /> :........... <br /> This Permit Expires I Year From Date Issued Date Issued .................... <br /> r 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 /> I / . <br /> JOB ADDRESS/LQCA ON . �.�} -- - .... ��....../`t'r-I/.�/..............................................CENSUS TRACT .................---...... <br /> Owner's Name . ......................... ............... .....................Phone ................................. <br /> Address . -. .�..1 ... eJ ...-.... ;'°`.• City ... ... <br /> Contractor's Name ��..... ......License # .1.� 3. z... Phone .......................... <br /> Installation will serve: Residence Eg"Apartment Houseo Commercial ❑Trailer Court 0 <br /> Motel ❑Other................... <br /> Number of living units:..-----Y.. Number of bedrooms .....Garbage Grinder .........:.. Lot Size .. '�?�` a .......... <br /> Water Supply: Public,System and name -•----•---....... ..........................................-••---....-•----................ ...............Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt o Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan 0 Adobe 0 Fill Materlal ............ If yes,type ............... ............ <br /> E <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-[ ]" ,, . Size............•................................... Liquid_Depth .........................1" <br /> Capacity . ------------------ Type -------------------- Material-------------......... No. Compartments .....................r <br /> Distance-to-nearest: Well ......Foundation . Prop. Line r <br /> LEACHING EINE [ ] No. of Lines ................. Length of each fine............................ Total Length .................... <br /> D' Box ---------..•`Type Filter Material .......Depth .Filter Material <br /> Distance'to,'nearest.. Well ............._........... Foundation ........................ Property Line ......................... <br /> + SEEPAGE PIT [ [ Depth ------_--------_ Diameter ---------------- Number ....................... Rock Filled Yes ❑ No 0� <br /> ----• <br /> Water Table-.Depth ---------- ............-........................Rock Size .......... ..................... C <br /> Distance to nearest: Well ----------- ............................Foundation ............ Prop. Line -----------_---__r <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........ -------------­---------------- Date ..........................,.......) <br /> Septic Tank (Specify Requirements) --------------•----------j---=-- <br /> - --- -......... ............................... ................................-.........--•................. <br /> Disposal Field (Specify Requirements} --- �__.�__f_�_- !--- -- 4 ,�� <br /> r .._ ........ ............... <br /> ----------------------------------.................................................................. <br /> ------------------•-- -------._-----....------------------------------------------------------............................. <br /> (Draw existing and required addition on reverse side) <br /> ! 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 /> - <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - --------- DATE .� .. L :.� ------------------- <br /> BUILDING PERMIT ISSUE=D ------ ..... - DATE - <br /> ADDITIONAL COMMENTS ----- ------------------------------------------- <br /> -----------------------------•-•----------------------------------...•----...--------•-• --••-------------------------------------------•--- ......-.............................................. <br /> .......................................................----:.......-......-.....---........-•--•-........----....----...... ..................................................................... <br /> Final inspection by: ...... :._ �&AQUIN <br /> .........•...............•--.....................--......--•-------.-Date ..L�..- f..- <br /> EH 13 2h J'-68 Rev. 5m LOCAL HEALTH DISTRICT 8/7!I 3M <br /> 121 <br />