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I <br /> FOR OFFICE USE: <br /> -------------- -------------------------I� - APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Triplicate) <br /> - - = <br /> --------- -------- --- ------ ---------------- I� <br /> - Date Issued <br /> --_----------------------------- This Permit Expires ires ] 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 Ord' ante No. 549 and existing Rules and Regulations: <br /> I <br /> F I ...... �Y--/-- CENSUS TRACT _. yq <br /> JOB ADDRESS/LOCATION .- - -`- 1 <br /> Owner's Name ------------.& -1----- � T-- ------>----------- -------Phone ------------------------------•--•-- <br /> Address ---- -- ------ -- - City <br /> Contractor's Name --- --- --- - --------------------------------------------------------—--------License # ---------:-------------- Phone -.-.-------------------------- <br /> Installation will serve: Residence C� Apartment House❑ Commercial Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units.._1------- Number of bedrooms _-.=f---_--Garbage Grinder ------------ Lot Size _------------------------------------------ <br /> __. I <br /> -.�..�. �.System and name ------------ -------------------- - ---------- ---- ------ �--------------------•--------------------- rivae ❑ <br /> Water Supply: Public Syst' --_ Private _ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt F] Clay E] Peat [ISandy Loam .Aff Clay Loam 0 <br /> jHardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing sizeVf lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: {M ,) <br /> o septic tank or seepage pit permitted if public sewer !s available within 200 feet <br /> PACKAGE TREATMENT 13 SEPTIC TANK'[ ] Size------------------------------------------ - Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------------- ------ <br /> II <br /> Distance to nearest: Well -----------------__---__---_-_-----Foundation ---------------------- Prop. Line -----_-----_-,_--___ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length --------------_---__-_-- <br /> 4 <br /> 'ID' Box ------ Type Filter Material --------------------Depth Filter Material -----------------------------------------•-- <br /> : Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ <br /> '7— <br /> SEEPAGE <br /> ---_-___-__-.-.- _._-.'7—SEEPAGE PIT <br /> Depth ---------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C <br /> I�Water Table Depth --------------------------------------------------Rock Size _.:----------------------------- <br /> Distance to nearest: Well ------------------------- ------.Foundation -------------------- Prop. Line _...--_-__..... ...... <br /> I! <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ---------------------------------- <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------------• ------------------------------ --------------------------- <br /> Disposal Field {Specify Requirements) ------ °d- -:-- - ----- --------------- <br /> I! --------- -- - - - <br /> T <br /> I ------------------------- i ------------- --- f ----- -T`---- . ----_--- - y-------. ----------_- .------ ----_.--_ <br /> --- ---•- ----------------------------- q <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I h lve 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 bet a subiect to Workman's Ckoppensation flaws of California." <br /> Signed ' r ? .--------- Owner <br /> BY ----- 11------------------ ------------- ------------------------ Title ------------------------------------------ ----------------------------- <br /> (If other than owner) <br /> a IN FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ----------------------------------------------------•-- DATE __ ^_ - ------•- <br /> BUILDING PERMIT ISSUED --------------------------------------------------------------------------------------------------------- <br /> ---- - -------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --- ------------------------------------------------------• -----------n---------------------------------------------------------------------------------------- <br /> ----------------------------------------ii <br /> f `---------------------------------------------------- - -------------------------------------------------------------------------------------------------------------...----- <br /> -------------------_-_- - --------------__-•----_-_--_-_----__.____----------______------------------ - <br /> Final Inspection by: Date ---/- - -'------------- ---------- <br /> -------- -------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> E. H. 9 1-'b8 Rev. 5M r <br />