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FOR OFFICE USE: APPLICATION 'FOR SANITATION PERMIT <br /> �` ------------------------------------ <br /> .,� Permit No: _7L--------- <br /> -- I <br /> (Complete in Triplicate) <br /> --------=------------------------------------------- --- <br /> Date Issued __. 1-2— <br /> ------------------- This Permit Expires 1 Year From Date Issued <br /> -------------------- ----------- XI <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 iNo. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION-._- - ____ _4?.=---_.1 .------------ ---- - - <br /> '---------- CENSUS TRACT <br /> Owner's Name ------ ----- - ------------- ---- -- ----------- --- ----------------- ------- `---Phone <br /> Address ---- ----------- (0� -- <br /> � � ------ - - --- - -- - -------- ..------. City: .. <br /> ------------------------- _.....---•------ <br /> Contractor's Name ---------------------- r �f!"? -----_--------License #/ f9 Phone ff�_,6_- 6 <br /> Installation will serve: Residence[Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑'Other . _ '---------------- f <br /> i R <br /> Number of living units:____(______ Number of bedrooms ____ _-__Garbage Grinder Lot Size _l�_ x_ _ _____________ +� <br /> Y ---- ' -----------------------Private X <br /> Water Supply: Public System and name ----- -- ---- ---- --------••-----��- ---------------------------------- -------- <br /> Character of soil to a depth of 3 feat Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> :Hardpan E] Adobe,) ] Fill Material ------------ If yes, type --•------ r <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:i (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ; <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth _------------------------- <br /> i Capacity --------------- Type -------------------- Material---------------------- No. Compartments -------------- <br /> Distance to nearest: Well ------------------------------------Foundation --------------------- Prop. Line ---------_--------••-- <br /> LEACHING LINE [ ] No. of Lines °----------------------- Length of,.each_Iin`e------ ---:----------------- Total Length --------------- <br /> D' Box _ �- <br /> , --.____ T.ypei Filter Material -.__________________Depth Filter Material ____________-_____-_-________---_-__-- <br /> Distance to nearest: Well`---------------- _ Foundation ------------------------ Property Line. ________-_____-__-_____ <br /> SEEPAGE PIT De th --____ Diameter '__ Number __________________________ Rock Filled Yes ❑ No <br /> [ ] pr. .tr , <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------------ <br /> fDistance to'nearest: Well'----------------------------------------Foundation;-------------------- Prop. Line ---------------- ---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________-_____-______:____.---- ) <br /> Septic Tank (Specify Requirements) --------------------- Y -- ------------------ -----•-•--------Disposal Field (Specify Requirements) ------------------------------------- -� -------- - --•----------- <br /> t ----- ----------- <br /> --. <br /> _ ______ _____ ___________ <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 /> "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> # a <br /> Signed -- - - --------------------- -------- - <br /> - -- Owner <br /> B ! Title ----- ' '----------------- ------------------ <br /> Y ----------------- - ---------=--------------------------- <br /> (if othe t an owner) <br /> F <br /> t . FOR DEPARTMENT US13 ONLY <br /> _ <br /> ----------- <br /> APPLICATION ACCEPTED BY ------------------------------------ ------------- -----------. DATE ---- r-----J ----- <br /> BUILDINGPERMIT ISSUED ------ ------------ ---------------------------t- = --- ---- ---------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -----------------------------------------------------s--�---- _---`-----�------------------------------------ ----------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -- ---------------- -------------------------0------------------------------------------------- ---------------------------- ---------------------------------- ---------------------------------------- <br /> ---------------------------------- ----- - - ------ <br /> Final Inspection by:-- U ----------------------------- -------------------- ------ ---- ---------------------------Date --- - - ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M ,J <br />