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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. .. <br /> .........................-.................... (Complete in Triplicate) <br /> J <br />...._......_..._....................................... Date Issued <br /> This Permit Expires I Year From Date Issued <br /> Application is hereby made to the This a San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. application is modelin compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 7 <br /> .. <br /> , � .............. ...... <br /> ................... ....CENSUs TRACT <br /> JOB ADDRE55/LOCATI N� 7--y'..• <br /> Owner's Nome _,: _.. _. .. :.....................Phone ................. <br /> Address _ ._._... -- # j P d....._.... City ...... j �.... <br /> -4 <br /> - , _. ..... <br /> _.... icense # _ . .. ._... Phone . <br /> Contractor's Name .__ . .. •-•-- <br /> installation will serve: Residence Apartment House❑ Commercial ❑Troller 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 /> Character of soil to a depth of 3 feet:I Sand❑ Silt El Clay ❑ Peat E] >.Sandy Loam ❑ Clay loam ❑ <br /> Hardpan C] Adobe'❑ Fill Material ___....!�. If yes,type ............................. <br /> (Plot plan, showing size of lot, lacotidn 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 200'feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK t ] Size....................•........... ................ Liquid Depth <br /> Capacity ...:............... <br /> Material--------.- ---._. No. Compartments t . <br /> Distance to nearest; Well = Foundation ...................... Prop. Line .......... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of each line----------.-•--------------v Total Length ...........:............. <br /> 'D• Box ....A...... Type Filter Material .....Depth Filter Material ...............................•-.._....:-•- <br /> Distance toIriearest: Well ..................r.... Foundation Property Line ___.........____....._.. Z <br /> Rock Filled Yes ❑ No <br /> SEEPAGE PIT [ ] Depth .... Diameter ....._----.---- Nurnber ...._____--_._..:.......... ❑ ' i <br /> Table Depth <br /> Rock Size ...... .......... <br /> Water . <br /> Distance to nearest: Well `...Foundation .- Prop. Line ................ S <br /> r <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................ Date .................................. <br /> Vert <br /> Septic Tank (Specify Requirements) ------­-------- ------....---------- -----------••-- .- :............................... <br /> ------ <br /> a <br /> q menta) e _ .. -!.' `� <br /> •--•............. <br /> Di y sal Field S eci a vire \- ( ................... <br /> i .................................................. <br /> -------------V- --------I------------------------------- ----------------_---------------- ...... <br /> IDraw 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 wills San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Iicen- <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 /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> l - <br /> APPLICATION ACCEPTED BY DATE -Y•.- ----••••------• <br /> r....... ......... <br /> BUILDING PERMIT ISSUED "' ..............DATE ....------...................._.....:_..__. <br /> ................................ ........ <br /> ADDITIONAL COMMENTS ' <br /> ...................................... ......................•---••---•---------- --..•-•-..--......._..._....----•-•......._.._.....-- _...:.-.......... .._.._. ....... <br /> Date ............... <br /> Final Inspection by: ....................... ��" <br /> SAN JOAQUIN LOCAL HEALTH_ DISTRICT ry . <br /> 7172 <br /> . <br /> 11 24-k in o..., CAA - <br />