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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> 6 �- <br /> ---- ------- - --------- -------------------- - I '- Permit No. ------1---1.`�-. <br /> (Complete in Triplicate) <br /> ------- -- -------------- ------------------------------ <br /> 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/LOCATON .- o ; '-- '-------------------------------------------------CENSUS TRACT <br /> Owner's Name --� - -- - ------ -------------------- <br /> - -- ------ ---------- -- <br /> Phone ------------------------- <br /> - ---- -- ---- - <br /> Address -----------.6 ---- --- -- ------------ City �' �------------------ <br /> --- -- -------- -------------------------------------- <br /> Contractor's Name .--- ------ -- -�----.L � 'J---.License # /�� 31l _ Phone <br /> Installation will serve- Residence ❑ Apartment House❑ Commercial ❑Trader Court `,❑ <br /> Motel ❑ Other --- -------- <br /> Number of living units:------- Number of bedrooms _-„---Garbage Grinder - --- Lot Size -----------------------_------------_----_-- <br /> Water Supply: Public System and name ------------ --------------------------------------R------------------------------------------------------Private E <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,] <br /> .+<' f 'r`S ----- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK;[� Size_________________ __ -- ---------------— Liquid Depth ------�______________-- <br /> Capacity --- Type `Material---(?-.jrv-4A4Z/aCompartments _. ----------- <br /> Distance to nearest: Well ----------_-/-C?-----------------Foundation --_-________---------- Prop __- <br /> Line .... --------------- <br /> LEACHING LINE [4o. of Lines -------/--------------- Length of each line---------5a------------- Total Length -------'Q................... <br /> D' Box <br /> `.-- Type Filter Material --.---5-R__----Depth Filter Material ------11--Q'---------------- <br /> Distance to nearest: Well --------- ---- Foundation -------- ------ Property Line --- -------------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No .0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ---------------------------•------------Foundation -------------------- Prop. Line ------_-__._-------.- <br /> REPAIR./ADDITION(Prev. Sanitation Permit# ------------------_------------------------ Date ---------------------------.------) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------•----------------------------.,.--------------------------- <br /> Disposal Field (Specify Requirements) ------------ ----------------------------------------------------------------------------------------- ---------- <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --- --------------- Owner <br /> -------------------------- ,_,Q� <br /> BY A''`'� "-y'"'. — ------------- -Title - ^- -L+�--+ s~v. <br /> ---------------------------- <br /> -------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------------------------------- DATE J- -- ------------------- <br /> BUILDING PERMIT ISSUED ---- ----------------- ----------------------------------------_------------- - --------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------- - -------------------- ----- ----------------------------------------------------- ------------------ <br /> ------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- <br /> ----------------------------------------------------- ----------- ----- -------------------------------- -------------------------------------------- ---------------- - <br /> ------------------------------- - :� ,, -- - <br /> 1 <br /> Final Inspection by: Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />