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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------- <br /> - <br /> -•--------------- (Complete in Triplicate) Permit No. <br /> ---------------------------------------------- This Permit Expires tl Year From Date Issued 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 witb,County Ordinance No., 549 and existing Rules and Regulations: <br /> S l.(� -w-Qv a� �.._e�4 2c <br /> JOB ADDRESS/L A ON . ,L- ---------- ---------------------------------- ----------------------------------Q-,- <br /> - CENSUS TRACT -------------- •---------- <br /> Owner's Name / - ------------•------------ ---Phone ---------------------- <br /> Address ------------- ---- -, - ----� - ---- -.-. City --- <br /> Contractor's Name ---___- A__�__ / ,_.License # -,1 YPhone -------------------- <br /> Installation <br /> _ <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court ',❑ <br /> Motel ❑Other '--- <br /> ` - "----- ------------------- <br /> Number of living units ---- Number of bedrooms ----'}'__.Garbage Grinder __________ Lot Size ___________________'-__.____ _____- <br /> Water Supply: Public System and name -----------------------------------------------------------------------------------------•-------•--•----------Private [ <br /> Character of soil to a depth of-3 feet: —Sand Q Silt❑ -Clay ❑ 'Peat❑ Sandy Loam.❑ , Clay Loam ❑ <br /> Hardpan [ J 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: fNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK�[k Size_ _�__�X_ _�_ '__ �_._________ Liquid Depth --` -�----------------- 4 <br /> Capacity ]�_�_ Type _ - __ Material--- --�----- No. Compartments <br /> ---------------------- <br /> Distance to nearest: Well --------„SQ__f_________________Foundation ------/0-_--_----___ Prop. Line ___-r�_____•______.__ <br /> LEACHING LINE [ No. of Lines ______. __________ Length of each line---------Sa---------.__ Total Length <br /> 'D' Box _____t____ Type Filter Material -----�`'_ ----Depth Filter Material ______� f� <br /> ------------- -----------•------- <br /> Distance to nearest: Well -----SP------------ Foundation -------_!_Q-.____.___ Property Line _____-4!�__--___.____- e <br /> SEEPAGE PIT [41 Depth _____ - ._ ___ Diameter --�� ._--_ Number ---_----.7r-_______-___ Rock Filled Yes ( ( No ❑ <br /> Water Table Depth ____-- �� -3 <br /> p -------------------- ----------------- Size -------�-�-�-----'-�-------- � <br /> Distance to nearest: Well ------------------Lb_0__{---------Foundation ...L(?........... Prop. Line ___-.51____________.__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------- ---------------------------•••--------------------------- <br /> Disposal Field (Specify Requirements) --------------------------- -------------------------------------------------------------------------------------------------------- w <br /> -------------------------------- ---------- -----------------------------------------------------------------------------------------------------------------------------------•------------------------- <br /> ------------------------------------ ------I------- <br /> ----------------------- <br /> ------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------- <br /> (Draw <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) 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 shalt not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of CaliFornia." <br /> Signed _.-------------- ---- - --- Owner, <br /> i------- <br /> By ------ -- -------- Title ------- <br /> ------ ---- <br /> - - ---- ----- -------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 8Y -•---- ------- ------------------------------------ DATE ------e1=4 7+------------ <br /> BUILDINGPERMIT ISSUED ----------- ------------------------------------------------------------------ --- ------------------------DATE -------------•----------------------- <br /> ADDITIONAL COMMENTS <br /> ----------------------------------------------------------------- --------------------------------------------------------------------------------------- ----------------------------------------------- <br /> --------------- --- ---------- -� <br /> -- --------- -- ----------------------------------------------------------------------------- <br /> Final Inspection by: y � <br /> L ---------------------•------------------------------------ --------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />