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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------- ------ ----- <br /> Permit No. - <br /> (Complete in Triplicate) <br /> ---- ----------- ----------------------------------------- Date Issued -�:_ .'�`�• ; <br /> This Permit Expires 1 Year From Date Issued i <br /> Application is heieby 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 /> // J i <br /> JOB ADDRESS/LOCATION .1- �_ _.__ '--- - CENSUS TRACT ------------- •- <br /> /� a �'�-- -TH------=------ ----- ----- hone --------------------------- -------- <br /> Owner s ----(/---�a:-- - ----- - -- <br /> C� /3l _ City1fN- , <br /> Address ,� _ s <br /> cJ <br /> ______.License # 7r',� — Phone <br /> Contractor's Name .- ---�� --- -- -- -- ----------- --------------- <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 /> Cbaracter of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [I <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 204 feet,) <br /> 1 v <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size--- --------- Liquid Depth - ar}---------------- <br /> Capacityi!;We----. Type Compartments Compartments __fir--------------- <br /> r � I <br /> Distance to nearest: Well ____-Foundation ____/________________ Pro Line _±�---------._ <br /> d-- -------------- p <br /> LEACHING LINE [ ]-_,:' .No. of Lines -------------- Length of each line------ ------=-------- Total Length ,.� V0---.-..-------- <br /> 'D' -Box ..- --------- Type Filter MaterialDepth Filter Material -- ----------------------------•---------- ` <br /> i oe Ste' <br /> Distance to nearest: Well ----- Foundation ---- - ------------- Property Line_ _ _-----.________-_:---- <br /> SEEPAGE PIT [ ] Depth E ___ Diameter ----------------- Number _____.__-_----------------- Rock,Filled Yes ❑ No I❑ <br /> Water Table Depth ---------------------------- <br /> -----------Rock Size -------------------------------- <br /> I r <br /> Distance to nearest: Well -----------------------------------------Foundation <br /> ----------------- <br /> -- Prop. Line ----------.....------- <br /> I --) <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------•--------------------- ------------ Date ------=--- -------------------- <br /> I <br /> Septic Tank (Specify Requirements) ------ -- ----------- ------------------------------------------------------------------------.------------------- ---... <br /> Disposal Field (Specify Requirements) ---------- ------------- <br /> --------------------------------------------------------------=--------------------------------------------- <br /> t ---------------------------------------- ------------------------------------------ ----------------------- <br /> _ . <br /> l (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 Work an's Compensation laws of California." <br /> Signed _ -------- -- -------- Owner <br /> g - - -- <br /> BY -------------------- Title - ! <br /> -------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 6Y ---- DATE -ter -- --��- ------------------- <br /> BUILDING PERMIT ISSUED --------,-`------------------- DATE i <br /> ADDITIONALCOMMENTS -----------`-------------------------------------------------------------------- ---------- ----------------------------------------------------- -------- <br /> --------------- l------------------------------ <br /> - ------------------------------------------- ----------------------------------------------------- <br /> ' <br /> ---------------------------------------____ _ _____ __________ w_..-_____ _-_____-_--_______________--___________-__________.______-__-________ ________�v e � _ _ ____-_ <br /> Final Inspection by.-_ Date ----------- <br /> ------ - ---------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />