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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----- -------- ------ ---------------------------------- E. — Permit No. _. <br /> (Complete in Triplicate) <br /> --------------------------- ✓ <br /> tr°�, Date Issued <br /> -------------------------------------------------------- This Permit Expires 1 Year From 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 /> JOB ADDRESS/LOCATION ---I------- - --_- %`--C2 to �� ill -------(R-P-----------------------CENSUS TRACT -----�_y.-l-----..._. <br /> Owner's Name ------- ----------- 1 1* 1r i ---------------------------------------- - -----------------•-------------------Phone " _--__----- <br /> Address --------- ------------------ `------------------------------------------------------- -•--•-- City --- ---------------------------------------I------ ---------- <br /> Contractor's <br /> 4-------------------------------- - -•- <br /> Contractor's Name ---------- C=tbff ----------------------------------- -•--------.License # ---------------'---- Phone --------------------------- <br /> Installation will serve: Residence ❑ Apartment House-[] Commercial )]Trailer Court ;❑ <br /> Contractor t Address S� K License No. �_Phone <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 Loamll <br /> Hardpan ❑ Adobe.0 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 [ ] Size--------------------------------- -------------- Liquid Depth --_---------.---.--------- <br /> Capacity ------------- -- --- Type -------------------- Material---------------------- No. Compartments ------------------ <br /> Distance to nearest: Well ------------------------------------Foundation ---_------ ----------- Prop. Line ---------------_...... <br /> LEACHING LINE ( I No. of Lines - --------- ------------ Length of each line---------------------------- Total Length ---------_---------------- <br /> 'D' <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 I❑ <br /> WaterTable Depth ------------- ----------------------------------Rock Size ----------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------.......... <br /> �[ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________) <br /> f Septic Tank (Specify Requirements) ----------------14900# ------------------- •--------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ---------------------------------•------------------------------------------------------------------------- ----------------- , <br /> ----------------------------------------------------------- ---------tin, xz r ------------------- -------------------------------------------------------------- <br /> ----------------------- ---- - ----------------------------- ----------------------------------------------------- ----------------------------------- <br /> (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 <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 -- <br /> Workman's Compensation laws of California." <br /> Signed -- - - -- ' -� L--- Owner <br /> BY --- - --- ----------------------------- ------------ -------------------------- Title .----------- - - <br /> ----------------------------------------------------- <br /> {If other than owner) <br /> FOR DEPARTMENT, USE ONL2Y <br /> APPLICATION ACCEPTED BY ------------------------------ ------ -------- ------ Ll DATE _..f/A ../�-)r-------------------- <br /> BUILDING PERMIT ISSUED f DATE <br /> ------ ---- ---- ------------ <br /> ADDITIONAL COMMENTS ------------------------------------ ----- - --------------------------------- --------------- ------------------ <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------•- <br /> FinalInspection by: ---------------------------------------------------------------------------------------------------------------------Date -------------------------------- ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M C0 <br />