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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- -------------------------------------------------- -- Permit No. <br /> (Complete in Triplicate) I <br /> -..-----I------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued ___ /7-! <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 with County <br /> Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -. --.-_� _--_�! s- _t - _. r----------CENSUS TRAACCjT -------------- ----------- <br /> Owner's Name ' -'�?`_- ,---- Phone T ' <br /> Address `�.91� ----- '-- -------- 1 -------------------- City ' ------ -- <br /> �-/�� <br /> Contractor's Name :---_.-_ -�- � ----------------------License # �______ Phone ? _'� '�'�._.-- <br /> Instaliation will serve: Res idence)R:�partment-House:❑_Commercial ❑Trailer,Court l❑ <br /> Motel ❑ Other ---------------- <br /> .e' <br /> Number of living units:-- ------ Number of bedrooms -__Z--___Garbage Grinder .----_-__ - Lot Size _-�Q-� �OE'------------------ <br /> Water Supply: Public System and name --- - --- ....... ------- .�_-;-------------- - - ---------- ------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ C[ay ❑E 'Peat❑ Sandy.Loam F1, Clay Loam ❑ <br /> } Hardpan ❑ Adobe Fill Material --'-- - If-yes, type'........................... <br /> F i <br /> {Plot plan, showing size of lot, location of-system in relation to wells, buildings, etc. mustfbe•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 [ ] Size-------------------------- ----------------__ -- Liquid Depth --------_-----------_-._.. <br /> Capacity ------)------------- Type -------------------- Material--------`------------- No. Compartments -----------------•---- <br /> Distance to nearest: Well -----------------------------}------Foundation ---------------------- Prop. Line ---------------------- <br /> ---- Length of each'line------------------------_-- Total Length ------------_ <br /> LEACHING LINE ( ] No. of Lines�-------------------- g 9 -------------•- <br /> 'D' Box .------i.... Type Filter Material --------------------Depth Filter Material ___-_____-.---------------_------------.---- <br /> Distance to nearest: Well -------------------------..Foundation __r__.------------------ Property Line -___--.._...-----.---_- <br /> SEEPAGE PIT [ ] Depth --------- ----- -- Diameter ---------------- Number. ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------- r----- ---Rock Size ---------------------------•---- <br /> Distance to nearest: Well --------------------~-__---------------Foundation -------------------- Prop. Line -------_----._.----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit�# _-__}_. ------------------------------------ Date ------..-----__ ---_-----_--------1 j <br /> Septic Tank (Specify Requirements) l-- ---------—----- ------ <br /> Disposal Field (Specify Requir(ments ---------- ------ -P----- '''v <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 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 /> BY --------------------------------------- <br /> ----------- Title __ .- <br /> -------------------------------------- ----- ------------------------------------------- <br /> i (If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------------- DATE --- --7 <br /> BUILDING PERMIT ISSUED --------------- /--------------- <br /> ------DATE _.-----------._---------.-- <br /> --------------------------------------------------------------------- -------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------•---------------------------------------------------------------- ---------------•----------- <br /> A <br /> - <br /> -------•-------------------------- --------- -- --- - --- -------------------- ---------------- ---------------- -- -- - --------------------- <br /> ------ ------------------ --------------------------------------------------------- ---------------- -------------------•------- ------------------ <br /> ------------------ ----------------- ------- <br /> FinalInspection by: ------ ---------- - --- ----- ---------------------------------------------------------------------------------Date -----I — ---------------- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />