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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. _____________________ <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> -------_-----_---------------------_--_---_---_---- , <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 ADDRESSAOC N :C--- --------------------------------CENSUS TRACT ----`-- --------------.-- <br /> i d C F <br /> Owner's Name --- -- -- ------Phone ------------------------------------ <br /> Address 9�J�� f J t City f -------------------------------- <br /> Contractor's Name -------- License # -IX,00 ?- Phone ------------------------------ <br /> Installation will serve: Residence partment House Commercial Trailer Court <br /> Motel ❑ Other ---------- --------------------------------- <br /> Number of living units:------t---- Number of bedrooms PL____Garbage Grinder ------------ Lot Size ---------------_,_____----________________ _. <br /> Water Supply: Public System and name _____________________ __ -__Private j <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ ±Gay ❑ Peat❑ Sandy Loam -❑ Clay Loam:❑ <br /> F Hardpan �/ Adobe'❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in Irela on to wells, buildings, etc. must be placed on reverse side.) _- <br /> NEW INSTALLATION: I(No septic tank or seepage pitpermitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ,[ ] SEPTIC, <br /> TANK [ ] _ iSiie------------------------------------------------ Liquid Depth ---_---------------- <br /> k <br /> Capacity -------------------- Type --------------------- Material---- - - No. Compartments ------------...--=---- <br /> f <br /> Distance to-nearest. Well ---------- --------t---------------Foundation ---- ----------------- Prop. Line ----------------__---- 4 <br /> LEACHING LINE [ ] No. of Lines ------ ----------------- Length of each line---------------------------- Total Length ----------.---.---.-- •-•-- <br /> 'D'-.Box --- Type Filter Material _---F------ --------Depth Filter Material ----------_--.---_--------------------...... <br /> Distance to nearest: Well ------ ----------------- Foundation ------------------------ Property Line ._--_.-._.-_._.___-_-__- <br /> SEEPAGE PIT [ ] Depth __________________ Diameter Number ---------------------------- Rock Filled Yes ❑ No . <br /> Water Table Depth ---------------------------------------- -------Rock Size -=------------------------------ <br /> Distance <br /> -`-- ---------- - <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------------.--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------- Date ------ __________________________I i <br /> Septic Tank (Specify Requirements) ------------- --- -----------------------------------------------------------------------------------------:---------------------------- <br /> Disposal Field (Specify Requirements) -- --------���__-- --�--���- -----�-------/-------------------------- <br /> "Av <br /> .11- ---- �--- ----------------------------------------------------------- <br /> =-------------------------------------------------------------------------------------------------------- --------------------------------------------------- ----------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> i <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 California." <br /> Signed .- Owner <br /> -------- ---------------------- <br /> .. '' -------------------------------- w. <br /> BY ---- -------- -- - ---------------= ------------------- - Title - - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ----------------------------------------------------- -- DATE ----------------- 3 <br /> BUILDING PERMIT ISSUED --- --------------------------------------------------- -----DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------ ---- ---------------------- -- ------------------------------------- <br /> ------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- ------- ---- <br /> -- --- ------- --- ------- ----------- -- ----------------------------------------------------------------------------------------- ---------------------------- <br /> ------------------------------------- -- -----=--- <br /> --- --- ---- <br /> Final Inspection by: .------ Date -- -____- - <br /> ---------------------------------- -------------------------------- <br /> --- - ---------------- ---------------------- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />