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FOR OFFICE USE: <br />` 6 <br />--1�:-�--------- <br />APPLICATION FOR SANITATION PERMIT <br />..­ .1" Permit No. <br />(Complete in Triplicate) <br />r• Date Issued <br />This Permit Expires 1 Year From -Date Issued <br />----------------------------------------- <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 Ordinance No. 549 and existing Rules and Regulations: <br />� 7-- <br />---------��- <br />JOB ADDRESS/LOCATION .----- <br />-------- -----------CENSUS TRACT -------------------------- <br />Owner's Name -----------` <br />i Cit Y -- - -- - <br />Address ----------------------- <br />Contractor's Name ___________ __ ___. -- -- <br />0 - ---------------------------License #1VDS.1_1 ---------- Phone °A <br />installation will serve: •� i2esidence Apartment House �❑ Commercial :❑Trailer Court <br />Motel ❑ Other -------------------------------------------- t <br />I Lot Size ----r� /----------- <br />Number of living units:__1-_____ Number of bedrooms. -Garbage Grinde L? <br />" ❑ y Private El <br />Water Supply: Public System and name -------------------------------------- ------------------ <br />Character of soil to a depth of 3 feet: Sand'El Silt El 'Clay ❑ Peat, Sand Loam ❑ Clay Loam ❑ <br />Hardpan ❑ ` Adobe Fill Material --------- If yes, type --------------------------- <br />( r <br />Plot tan, showing size of of system in relation to wells, buildings, etc. must be placed on reverse side.) <br />p , <br />NEW INSTALLATION: _ (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br />s r , ► :Li uid Depth ----- <br />PACKAGE TREATMENT [ ] SEPTIC TANK f I ` q <br />! r L e--------------------- Material --------- fit ----------- No. Compartments ---------------------- <br />Capacity <br />_Foundatiori---------------------- Prop. Line -------------:------- <br />Distance to nearest: Well __________________________________ i " <br />-- Length of each line---------------------------- Total Length ------------.----------•---- � <br />I LEACHING LINE [ ] No. of Lines _______________ g J <br />--------.De th Filter Material ------------------------------•------------ <br />'D' Box ------------ Type Filter Material _________- p <br />Property Line <br />Distance to nearest: Well --- __---------- --------t Foundation' �- ---- ---------------- <br />Y <br />------------- p <br />SEEPAGE PIT [ ] Depth ____________________ Diameter _________--____ Number .._____---- Rock Filled Yes ❑ No <br />1 Water Table Depth_ 4'_------------------------------------- - - ---Rock- <br />Size -------------------------------- <br />Distance to',nearest: Well -------------------------------------- ..Foundation <br />--------------------- Prop. Line ---------------------- <br />Rl~PAIRfADDITION(Prey. Sanitation Permit --------- <br />---------------------- Dafi_- __ _ _-_-- ------------- f <br />Septic Tank (Specify Requirements) ------- ----- `s -- " <br />Disposal Field (Specify Requirements) ____________ ___ � r-- --- a� 4 <br />------------------ --------------------- -- <br />. . - AA----------------- <br />------ ------------ - --------------------------------------------------------- <br />' _=(Draw existing and required addition on reverse side) <br />4- - <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />Count 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 />Title - <br />-----f <br />---------------------------------------------- <br />A <br />----- <br />--------------------------- --- <br />BY - <br />-- <br />(If of than owner) <br />L FOR DEPARTMENT USE ONLY <br />DATE y <br />APPLICATION ACCEPTED BY --- - ----------- "` + 7--- - ----- <br />BUILDING PERMIT ISSUED DATE <br />ADDITIONALCOMMENTS----------------------------------------------------------------------------------------------------------------------- - <br />------------------------------------------------------------- <br />--- ----- ------------------------- <br />----------------------- / ------ <br />a <br />-------------------------------------------- - -- <br />Final Inspection by: Date T� J <br />SAN JO UIN LOCAL HEALTH DISTRICT <br />r u a 1 _'AR Rev_ SM <br />