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FOR OFFICE USE: <br /> APAICATtON FOR SANITATION PERMIT 7� <br /> Permit No. ---- r <br /> (Complete in Triplicate) <br /> ------ --------------------------------- /N <br /> Date Issued <br /> ------------------------------------------ This Permit Expires ] 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/LOCATIO -- `l-- - ------/- ---i---`- ---- - -------------------------- --- -- ------------ CENSUS TRACT <br /> Owner's Name Com`--- ------ - ----- . �}� - - Phone. � 7. <br /> Address S' ------------- City <br /> Contractor's Name ------------ ----- �'''r----------------------License # ------- Phone ------- <br /> Installation will serve: Residence ( ] Apartment House'[] Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:_-- _______ Number of bedrooms _____ --_Garbage Grinder -----------. Lot Size _.<_ - -Y--------•-------- <br /> x <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Privote,)� <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt f] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ J <br /> Hardpan ❑ Adobe X] 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 f ] SEPTIC TANK'[ J Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material------------------. -- No. Compartments --------- . <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING-UN <br /> -__-_--________------ V <br /> LEACHING-UfiN.E [ ] 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 /> -----._... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _---______------ Number ---.------------------------. Rock Filled Yes ❑ No <br /> Water Table Depth ----=----------------------- 3Rock-Size ._- ------------------------- <br /> Distance to nearest: Well -------------------------a-------------Foundation ------------------- Pro4p. Line --------- ------_--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit°# ---------------------------------------------date -------------;.-.-----------------} <br /> Septic Tank (Specify Requirements) ------------ -----------------------I ------------------.----------------------------- <br /> Disposal Field (Specify Requirements) ---------- _r-- -----vo--�---- - ------------------------------------ <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, I_shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of Califorriia." <br /> Signed --------- `-_ _ Owner F_�- <br /> BY <br /> (If �erthowner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYE _ - ------------------------------ DATE ........ 7 <br /> -- ,, <br /> BUILDING PERMIT ISSUED 1 l DATE . <br /> ADDITIONAL COMMENTS 6 1r �? 2------ , ,/ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - ------- ------------------------------------------------------------------n--------------------- ---------------------------------------------- -------------------------------------------- -- <br /> ------------ - --- --- <br /> Final Inspection by: _._.• ___-- _ Date ----_-- --- ---------- <br /> -- - - - ------- - --- ------ ------- <br /> "' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_ H_ 9 1-'68 Rev. 5M <br />