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w <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> - (Complete in Triplicate) <br /> - <br /> --------=----------------------------------------------- <br /> Date Issued <br /> ------------------------------------------------_-- This Permit Expires >< Year From Date Issued <br /> Application is hereby made to the an 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 -------------- Wit.------- _ _ _lct ► ..------ ^rzOENSUS TRACT `c7-/------ <br /> Owner's Name -- - ---- -------- - - -------------Phone --------------------------- <br /> ------------------ --- -- - <br /> s. rf�. City-✓��'vf------------------------------------------------••--- <br /> Contractor's Name ------------- ------------ -- -----License # Phone <br /> Installation will serve: - -Residence Apartment House❑-Commercial e❑Trailer-Court--i❑ -- <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------------ Number of bedrooms ________Garbage Grinder ----- ------ Lot Size ____- <br /> Water Supply: Public System and name ------------ -. -----------------------------------------------------------------Private [� <br /> - -- ------•--------------- <br /> Peat Sand Loam Clay Loam <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ ❑ y ❑ Y ❑ <br /> Hardpan ❑ c 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.} !f <br /> NEW INSTALLATION: (No septic flank or.'seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT, { ],_ SEPTIC TANK f-]__ Size-------------------------- --------- i Liquid Depth N <br /> Capacity ---------- - . <br /> _------ Typ? --------------- Material-- -------------- -- --- °e <br /> No. Compartments ------ ---••-• <br /> V <br /> Distance to nearest- Well Foundation ________ Prop. Lute ---------------------- s' <br /> LEACHING LINE [ ] No. of, Lines -___-- Len tlt of each <br /> g line--------------------- ------ Total Length ---------------------------- <br /> �D' Box ------------ Type Filter Material --------------------Depth*Filter Material ---------;---------------------------------- <br /> �I <br /> Distance to nearest: Well _-_----__-_____________ Foundation -_--_____------------- Property Line _.___-________-------- ] <br /> SEEPAGE PIT [ ] Depth i-------------------- Diameter ---------------- Number ------ -Rock Filled Yes ❑ No 0 <br /> ater Table Depth -- - ----.Rock Sizer'------------------- ------ <br /> Distance to nearest: Well ----------------------------------------Foundation` .------------------- Prop. Line ..--------------.--.•- <br /> REPAIRfADDITION(Prev.t Sanitation Permit# --------------------------------------------- Date ------------------------------------ <br /> Septic <br /> -------- -----Septic Tank (Specify Requirements) --------------- ---------------- -------------------- ............•---------------------- ---------------------------------- <br /> t 1.® ` ------------------------------------ <br /> Disposal Field ( pecify Requireme is} _____ i y�; <br /> ------------------------ <br /> ---------- <br /> -------- G <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 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 Com ensatio laws f California." <br /> Signed ' �'---,-r` r ------ Owner_ <br /> - <br /> BY -------------------------------------------------- ---------------------------------------------------• Title ------- ------ -------- ------------------ ----------------- <br /> - <br /> (If other than owner) <br /> OR DE ARTMENT USE ONLY <br /> 4� !�' <br /> APPLICATIONACCEPTED BY ------------- ---w---- = --------- ----------------------------------------------- DATE ---.-- . -_ /`BUILDING PERMIT ISSUED ------------------------ ------------------------------------------------------------------=--------------DATE ------------- ------------------------ <br /> ADDITIONALCOMMENTS ------------- ----------------------------------------------------•-------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------ -------------------- -------------------------- <br /> ---------------------------------------------------------------------------------------------------- <br /> -- --- -- --- --------------------------------- _ -------------- <br /> Date ._ 2 <br /> - -------------------------------------------------------------- --- -- <br /> Final Inspection by- ------------------- ------------ -- ----------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 <br /> E. H. 9 1-'68 Rev. 5M - <br />