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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- -------------------------------------- <br /> (Complete <br /> ------------- ------ (Complete in Triplicate) Permit No. <br /> -------- ------------------------------------------------ <br /> ------------------- <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 /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> - <br /> JOB ADDRESS/LOCA I __ ------ --- �--`-�----- -- --------- CENSUS TRACT <br /> I _:. . <br /> - <br /> ---------------------> one -------------------------------- <br /> Owner's <br /> ----- --------- <br /> wner's Name <br /> Address . --- _ • = city <br /> - ---------------------------------------- <br /> Contractor's Name - ------------- .License # � ehone <br /> Installation will serve: Residence- artment House❑ Commercial:OTrailer Court-C1-- <br /> Motel <br /> --•--- --Motel ❑Other -- ------------------------------------- Lot Size ":2 a-,Z� <br /> Number <br /> ---- -------------------------Number of living units:- ---- Number of bedrooms ��Garbage Grinder �`____----- Lofi Size _�___________________________________ <br /> Water Supply: Public System and name --------------------------- <br /> ------------1`--------------------------------- -------------v ------------PFivatei.- <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ �Clay ❑ Peat❑ Sandy LoamClay Loam <br /> ! Hardpan ❑ Adobe '❑ Fill Material ____________ If yes, type ____________________________ <br /> - r <br /> (Pl'oi plan, showing size of lot,' location of system in relatidn.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,j �. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK! Size------------------------------------------------ Liquid Depth .------------------------- <br /> Capacity ----------- ------ Type .---------+------ Material---------------------- No. Compartments ----------------- <br /> .---- <br /> Distance to nearest: Well _--------�. _-------"^---_-------Foundation ---------------------- Prop. Line --------------•--•--•- <br /> 6 d <br /> LEACHING LINT= ['] No. of Lines ---------------________ Length of each line---------------------------- Total Length ,__-__--___.._......._..__.. <br /> t 'D' Box _____ -__:- Type- __L____ <br /> r Yp ---------..Depth Filter Material - ---------------------•-•----------------•- t <br /> Distance to nearest: Well ----------------------- Foundation ------------------------ Property Line. ---------------------- <br /> SEEPAGE <br /> -----------•----- -SEEPAGE PIT [ } Depth ____________________ Diameter ---------------- Numbe, ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> ­—Distance <br /> -------------------------------...-.Distance to nearest:-Well,---=----------------------------=--------Foundation--------------------- .Prop.:Line,..--------------------- <br /> � iE <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _______ ------------------------------------ Date ___________________________-___-) <br /> SepticTank (Specify Requirements) ------------------------------------ -----------'--.� --------------------------------- -------------------..------------ •- ------- <br /> Disposal_Feld (Specify Requirements) ----- �-_ 6_e) r <br /> -- --------- ---- ----------------------- -- -- <br /> F <br /> a__ e------------------------ <br /> ------------------- <br /> -------------------------------------------------- ------------------------- -------------------------------------------------------------------------------------------------------------- i <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 /> "1 certify that in the performanceof the work for which this permit is issued, I shall not employ any person. in such manner <br /> as to become subje orkman's Compen atio laws of California." <br /> Signed /_----------- Owner <br /> ---- . <br /> BY ----------- -- - ------� � Title ------ ---- ----- ----------------------- -------------------- <br /> f other than owner) <br /> FOR DE AATMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------ - - ----------------------------------------------------------. DATE//'_ _r ------------------- <br /> BUILDING PERMIT ISSUED ----- DATE <br /> -------------------------- <br /> ADDITIONALCOMMENTS - --- ------------------------------------------------ ------------------------------------- --------------------------- <br /> ------------------------ - ---------- <br /> ----- ------------ ----------------------- ----------------- - - - ------ ------------------------------------ - - - ------------------------------------------------------------------•---- <br /> -- -- ---- <br /> -- <br /> •� - ;€ <br /> Final Inspection by '-. e - <br /> ------------------------------------------------------------------------- Dato ------- --------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s <br /> E. H. 9 1-'68 Rev. 5M, <br />