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FOR OFFICE USE: <br /> r APPLICATION FOR SANITATION PERMIT <br /> •......... .... ._..__.. .. .-.• ---•••.............. <br /> (Complete in Triplicate) Permit No. ............. <br /> ............................................... This Permit Expires 1 Year From Date Issued <br /> 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 � _ -_ -- ----- - -- - -------------- ....................CENSUS TRACT ............._...... <br /> Owner's Name ... .. �.. .-•-•...............•- --- ... • ...-....._ Phone _......... <br /> . .. --------- <br /> Address .......... _. .JrT-�.....k.! --• - - ----•- ...&'city .•._.._. ... --•---•-- -------------------------------•........ <br /> Contractor's Name--..._ J `.fL. ..License # �Phone .................. <br /> Installation will serve: Residence [Z portrn House <br /> Commercial ❑Trailer Court r:❑ <br /> Motel ❑Other............................................ <br /> Number of living units.-_!....... Number of bedrooms 2......Garbage Grinder ..2.o.... Lot Size ---,?.,4J"_?fe..J.......... <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 Loam 'O <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 [ij/ Size x�. /X 4--------------------- Liquid Depth ._4 ..�..•........-... ��. <br /> Capacity Type .............. Material_mEOV-4A4.4'- No. Compartments --- ............ <br /> i <br /> Distance tc neares . Well ._.----------4rl?..................Foundation .... --._ Prop. Line....; .......... <br /> LEACHING LINE [ No. of Lines ........... .......... Length of each line.......441q_........... Total Length ,.../ .............. (/} <br /> 'D' Box ..- ,_P____ Type Filter Material ..-.5� ......Depth Filter Material ......../_�1.............................. <br /> Distance t nearest: Well -----------.�---.------_ Foundation ........................ Property Line _�............ .... ,\` <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ................ Number ------.--_------.-.-.-----. Rock Filled Yes ❑ No is <br /> Water Table Depth ................................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation•:......-.-.-.------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date --------- ....................... <br /> Septic Tank (Specify Requirements) -----------------------•-•-•-•-•---•-•----------------------------------------------------------------------,-----------•--------------- <br /> Disposal Fi d (Specify Requirements) ---------------------•-------- .. . .. <br /> ............ <br /> / - <br /> ................•------------------ ----- ----- --- .............-----3 <br /> (Draw existingand 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 Son 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: S <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 becomes j t to Workman's Compensation laws of California." <br /> Signed ............. ............................ Owner <br /> By ............. -•--• �than <br /> . <br /> -•-- -• -----.-a .................... Title - <br /> (If oowner) <br /> FOR DEP NT USE ONLY <br /> APPLICATION ACCEPTED BY ....' - _._.... .- .............. DATE <br /> .. ......................-----------••--•--........------••-------•- --/----......-----•--- <br /> BUILDING PERMIT ISSUED ---•-------•---------------- - ...................DATE ._.._.--........... <br /> ADDITIONALCOMMENTS ------------ --- -••--••-•••••---•------••------•----._.....•• -••------•••••......••----...--------•-•-••••----............----••--....--•------•--------- <br /> ............... ................................------------------•----------- -••---•••-•......----•--•--•--•----...................---------•...-•-•------•-•----•--•----•--------•-•--.............---- <br /> ...........................•... • --------- --- ------------------------------------------------------------------------------------------------•......-_----------- --- ................... <br /> . <br /> Final Inspection by:,: :^�� r�- ...................................... .............................................. .Date .[ � cS...-.. U--- --.-. -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />