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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> ,,. (Complete in Triplicate) l <br /> Date Issued __`. q <br /> --------- this Permit Expires I Year From Date Issued / <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and 'install the work here'. t, <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulationsr <br /> JOB ADDRESS/LOCATIO 1 - ___--_ - -- -----CENSUS TRACT --=-- -------- <br /> ----- <br /> ------ --- #-V <br /> - ----------------------------------------------- -- <br /> Owner's Name ak.- - --- --- ------------------------------------------------ -------=-------------------Phone -------------------- ----------• <br /> 0--1---C3 � �1 <br /> Address ----- ----- ---------------------------- City = <br /> s r --- <br /> Contractor's Name ---- - --- ---- - License # Phone - -------------------- <br /> Installation <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------- <br /> Number of living units:----l------ Number of bedrooms _9�---Garbage Grinder .____ Lot Size _- _ !g. ________-_____-__-____- <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 0 <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 flank or seepage pit permitted if public sewer is available within 200 feet,) \ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'S ] Size------------------------------------------------ Liquid Depth ---------------------.----- V\ <br /> Capacity --------------------- Type -------------------- Material---------------------- No. Compartments ------ ----=---- <br /> Distance to nearest: Well ------------------------------------Foundation ----------------------.Prop. Line -----------_---..----- \� <br /> LEACHING LINE [ ] No. of Lines ------------------------ Ler gth of each line---------------------------- Total Length -----------_---------_.---- <br /> r <br /> 'D' Box ------------- Type Filter Material ---------------------Depth Filter Material ---------------------------------------...... <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line- ------X:__:-------------- <br /> z <br /> SEEPAGE PIT [ ] Depth -__--------------- Diameter ---— Number ------------------------I--- Rock Filled Yes ❑ No .0 <br /> Water Table Depth ------- -I-----------;L_1--.`-------------.--.,R_ock Size --------------------- <br /> Distance to nearest: Well -------------------------'----__. --... Foundation ----------_- -- - Prop. Line -•--------------....._ <br /> REPAIR/ADDITION(Prev. Sanitation.Permit# -----------------------------------------__" Date ----------------------------------) <br /> t , <br /> Septic Tank (Specify-Requirements) -------------------- -------------- -- -----{ <br /> ------------------- --- <br /> Disposal Field {Specify Requirements) -----�,--- '�-� ---...--- l � -------------------------------- <br /> --------------------- -------------------------------------------------------------------------------------- ------------------ -'------------------------------ <br /> -------- - -- - ---------------------------------------- --------------------------------------------------- -------------:---.:--------------------------------------------------------------------------- <br /> (Draw existing and required addition ori 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 LocalHealthDistrict. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance o(the work for which this permit is issued, I"shall not employ any person in such manner <br /> as to become subi ct to Workman's Compensation laws of California." <br /> SigneS I <br /> - ------------------ - ------ - ------------------------------------------------------- Owner <br /> BY # ----------------------- Title ---------- - -------------------- ------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----N -------------------------------------- -- . DATE -3— ----------------------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ----------------------------.------------- <br /> ADDITIONALCOMMENTS -- ---- ---------- -------------------------------------------------------------------------------------------------- ---------------------------------------- <br /> ----- <br /> --------------------•- ------ <br /> -- -- --- ------------------------- -------------------------------------------- ------------ ----- <br /> --------------------- ------------------------------------------------------- ----------- <br /> - - <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ <br /> ------ ----- ------------ ---- <br /> r <br /> Final Inspection by: . _ V------- ------Date -, .. <br /> -_ --- _ :::_____________ ___:::_ _ : :-:::::_: <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />