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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT %% <br /> -- Permit No: _[l�-L-`-Ud <br /> (Complete in Triplicate) <br /> ---------------------=----------------------------------- a 3. <br /> _---___--__--- This Permit Expires 1 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 /> descfibed. This application is made in compliance with County rdinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION_.-` �- r -------- -------- - ----- --- --- -=---------------CENSUS TRACT -------------- ----------- <br /> -Name Phone - <br /> - ---------------------------- <br /> Address ---- --------- --- --- ------------•- City ._ -----•----- -------- ---------------------------- <br /> - <br /> Contractor's Name ----_- - _ 2_____________License#1r-. 3 one -----------_-_----------------- <br /> - == - --- t - <br /> Installation will serve: Residence ZIApartment House❑ Commercial :❑Trailer Court ❑ <br /> Motel ❑ Other ------ -----------------------------------•- <br /> Number'of living units------I/-_ Number of bedroom----Garbage Grinder ------------ Lot Size ----- _ _______ _______ _ �. ., <br /> Water Supply: Public System and name --I---- -------------- --------------------------------------------------------------- -----_Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Clay ❑ Peat ❑ Sandy Loam Clay Loam:❑ <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 f ] SEPTIC TANK.f ] Size-------------------------------------------------- Liquid Depth -------_------------,----- �r <br /> Capacity -------------------- Type -------------------- Mateiialr.:---- No. Compartments --------• ------------- <br /> Distance <br /> ----- ----Distance to nearest: Wel( -------.Foundation _- -------------------.Prop. Line --------------- ------ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line--------------------- -------Total Length _------ ..--....-- j <br /> Deth Filter Materia! _"__'�_.- <br /> 'D' Box ----------- Type Filter Material -------------------- P ------------------•--•--------.---• <br /> Distance to nearest: Well ------------------------ Foundation ------------------ �" Property Line --_----_----.-----.:..._ <br /> SEEPAGE PIT [ ) Depth ---_.--.--. ' f_----- Rock Filled Yes---- '- Diam�er----5�----'�Number�--:�-------- _ <br /> WaterTable De th ------------------------------------------------Rock Size ------------------------- ----- <br /> Distance to nearest: Well ------------------------------------....Foundation- -------------------- Prop. Line -----------.-_-. -_.. <br /> REPAIR/ADDITION(Prev. Sa-nitation Permit# --------------------------------------_-R <br /> {{ -�- --- Date ----------------------------------} <br /> Septic Tank (Spgcify Requirements) -------------------- -- ------ ----------------`- ------------------------ -------------..---------------•----------- <br /> Disposal Field (Specify.Requirernents) L --- _----- T <br /> ,... J//es� � —, - <br /> _-_______ �!•-------r---- - ' ~--{=mss__'-_-`--------------------------------------- <br /> ------------------r-----_------- -------------------_----•--•-'y- •---•-------------__-----_---_-•----------_----_------ <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 ar licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becom ject to Workman's Comp ion laws of California." s <br /> Signed - ----- ---------------- ` ----- - Owner <br /> SY -- -- ------- ----- ------------------------ ---- ---- ------ - ----- __ you' Title <br /> (If other than owner) # O <br /> FOR DEPARTMENT USE/ONLY <br /> C <br /> APPLICATION ACCEPTED "BY - -----------------------------------------—_ ----- - -----------------------------------. DATE -- -----�--J----- - ----------=--- <br /> BUILDING PERMIT ISSUED ------- ----- ----------- -------------------------------- --- ---- --------------DATE ---------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------- --------------------------------------------------- ---------------------=----------•---------------- <br /> ------------`----------------------------------------------------------------------------------- <br /> - -----------I---- -- ------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------- <br /> -------------------------------' -------------- - -------------------------------------------------------- -------��-,4— -----------=•------ <br /> Final Inspection by: - -----=------------Date -------------------------------------------- <br /> SAN <br /> ---------------------- ----- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br /> .:7 <br />