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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------------------- Permit No.�-1--VT <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> ------ Date Issued �-Q---�"- _�.. <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 wit Count rding4ce.No. 549 and existing Rules and Regulations: <br /> al6 <br /> JOB ADDRESS/LOCATION ----------- - <br /> ---------------------- F ------ -- <br /> ---_CENSUS TRACT --.---_------------------ <br /> .... . . -------.Owner's Name - - ------ __ -- --- --- ------------ ------------------------------ <br /> Address ' Po <br /> iQ - City � 40 <br /> - <br /> Contractor's Name ----------------------------------------------------------------------------------------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 -----------------------------.._-_-_---.-.. <br /> Water Supply: Public System and name ----------:----------------------•----------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ 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 [ ] SEPTIC TANK [ ] Size---------------------`------------------------- Liquid Depth -__-_-------_-------_--___ <br /> Capacity ----------- -------- Type -------------------- Material--------- ------------ No. Compartments ----------------....--, J <br /> Distance to nearest: Well ---------- --------------------- -.-Foundation ---------------------- Prop. Line ---------------------- /�" <br /> LEACHING LINE [ ]L No. of Lines ------------------- -- Length of each line---------------------.------ Total Length -----------•---------------. O <br /> 'D' Box .--_--�---. Type Filter Material --------------------.-Depth Filter Material _----.--_------------_-_--_-__._._--_-- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---------.-_.-_--.-.--_Z <br /> SEEPAGE PIT Depth -------------------- Diameter --------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ---------- --------------------- <br /> Distance to nearest: Well ---------------------------------------Foundation -------------------- Prop. Line -_----_-____-_-_-___-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> .-Septic-Tank (Specify Requirements) ------- ------------------------------------------------ ------------------------••---------_------ --------- <br /> Disposal Field (Specify Requirementtss)) ------- -- ,-f• - -�4c.Q--------V---� - J� --- `f---------------- <br /> . -�-----9----- ---------d e- ---•------------------------------------------- ----------------------------�------- .. <br /> ------------------------------ -------------- -------------------------------------------------------- ------------------------------------------------------------------------- - ------ r <br /> (Draw existing and required addition on reverse side) <br /> l 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 ---------9 Z ------------------------------------ Owner <br /> -------- Title --------- -------------------------------------------------------------- <br /> [If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY =-------------------------------------------------------------------------- DATE ''- _ - ---------------- <br /> BUILDING PERMIT ISSUED --- -------------------------------- -------------------------------------- ------------- -----------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------•- ------------------------------------------------ ------=--------------------------- <br /> ------------------------------------- ------------------------------------------------------------------------------------------.----------------- -------------------------------------------------------- <br /> ------------------------------------------------ ------------------I------- <br /> ------------------------------------ -- ---- - -- ------------------------------- --------------- - ----------------------- --------- <br /> Final Inspection by: ---------------------------------------------------------------Date _..7--� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />