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r <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----- <br /> (Complete in Triplicate) Permit Na. <br /> -- - -- ----------------------_----- <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> - _- --v <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 <br /> made in compliance with Country Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION, / - -------•----- -- ------CENSUS TRACT <br /> l Phone ------------------------------------ <br /> Owner's Name ------ - - - -- � <br /> = <br /> Address ------ <br /> . City3- <br /> Contractor's Name/ ,t� License # � a -- Phone - <br /> Installation will serve: ResidenceMApartment House❑ Commercial []Trailer Court ;❑ <br /> Motel ❑ Other --------------------------------- ---------- <br /> Number of living units:-__ ---- Number of bedrooms J?------Garbage Grinder LotSize �_f•R -------- <br /> Water Supply: Public System and name ------J_��7 ----- •---------------------------------------------- ------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 /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size---------------------------------------------1Liquid Depth -------------------------- <br /> Capacity --- ----------- ---- Type -------------------- Material---------------------- No. Compartments ------------- ........ d <br /> Distance.to nearest: Well ------------- - -------------Foundation ------------------ _- Prop. Line --_.-------_-._.._-_-- <br /> LEACHING LINE [ ) No. of Lines ------------------------ Length of each line--_ +_ ------------------ Total Length -----------.-------......... <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------- -------- ------------------------ <br /> Distance to nearest: Well ------------------------ Foundation ----------------------- Property Line -------.-.---------_-- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------- _--- Numbe- ---------------------------. Rock°Filled Yes ❑ No C <br /> WaterTable Depth ------------------------------------------------Rock Size --------------•----------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------..----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit=# -------------------------------------------- Date -----------------------.---------- <br /> Septic <br /> --------Se tic Tank JSpecify(SpecifyRequirements) ------------------------ --- --------- _ .. ------ <br /> --------- <br /> Disposal Field (Specify Requirements) -_- - _- ---- --- i -- - f <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 /> "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 Campe tion laws of California." <br /> Signed --------------- --- -- -- -------------- ------ ------------------------------- Owner <br /> r <br /> w <br /> TitleBY --------------------------- <br /> Vn[If r than own r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- --- --------- ---------------------- ------ DATE -- -------------- ----------------------- <br /> = --- <br /> BUILDINGPERMIT ISSUED -•-------------------------------------------=----------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ----------------------------------------- -`---------------------------------------------- ------------------------ ----- ----------------•-•---------------- <br /> --------------------------------------------------------- ---------------° ------------------------------------------------------------- <br /> --------- ------------------------------------------------------------------------------------ ------------------------------------------- <br /> ----------------------------- <br /> p Y ---- - <br /> Final Ins ection b - --------------------------------------------------------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT µ <br /> E. H. 9 1-'68 Rev. 5M <br />