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�T <br /> FOR OFFICE USE: �` <br /> APPLICATION FOR SANITATION PERMIT e/ <br /> -------------- f Permit No: . <br /> (Complete in Triplicate) <br /> ---------------------------------- ----------------------- <br /> r Date Issued -24-_2_`�~�� <br /> -----__--------------------- - This Permit Expires 1 Year From Date Issued <br /> 1 <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 oun_ty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT N 1 ..-----CENSUS TRACT -------------------------- <br /> Owner's Name --- ----- ------ ------- Phone - <br /> i Address ------�t-�. ------- --- --- - .-�° 1�-"9-0�---------------•... City ---- <br /> ---------------------------------------------------------- <br /> t <br /> { Contractor's Name - -°------------------------- <br /> ----------- --------License# ------------------------ Phone -------------------- <br /> Installation will serve: Residence ❑ Apartmenfi House❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑Other ............................................ r <br /> Number of living units ------- Number of <br /> bedrooms _-�;"k-`-Garbage Grinder ------------ Lot Size _.__---------------_____________-------- <br /> k 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 ❑ <br /> Hardpan ❑ 'Adobe ❑ Fill Material ------ ----- If yes,type _______________________-- <br /> I • <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> t <br /> r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SE r <br /> tk � } SEPTIC TANK'{ ] Size-----=------------------------------------------ Liquid Depth ---------------------.----- <br /> f Capacity.--------------- -- Type --------------------- Material---------------------- No. Compartments ------- ------ <br /> Distannt ...... <br /> LEACHING LINE No. el to nearest: Well --------------_-----------.---------Foundation _-------------------- Prop. Line --------------- <br /> �,�/ Lines ------I---------------- Length of each line--------- ------ Total Length --------------.-----------.. <br /> 'D' Box; Type Filter Material --------------------Depth Filter Material -------------------- - <br /> CDistance to nearest: Well ________________`_______ Foundation _____ Property Line ----__-___________._____ <br /> SEEPAGE PIT Me Depth --�_ �__________ Diameter ...........fir -_ �____ __ Rock Filled Yes j /'No ❑ . <br /> Water Table Depth ---------------------- ----------------•--------Rock Size -------------------------------- <br /> Distance I to <br /> ------------------------------Distanceto nearest: Well ________________________________________Foundation -------------------- Prop. Line _____.___._____.....-- <br /> - f <br /> F REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------------- <br /> Septic <br /> ------------------.--------------Se tic Tank (Specify Requirements) ------------------------------------------------------------------------------------------------•----- <br /> r <br /> -------------------- <br /> Disposa Fie { peyaiements) --------------------------••--------=--' - <br /> - - - - - --- ---------------------------- <br /> i <br /> --------------------------------------------------------------------------- ------------------------ <br /> ---------------------------------- --------------------------- <br /> ------------------------ --- ------------------------------ ------------------------------------ <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 JoaquinY <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 beco a ubject Workman's Comrnsation laws of California." <br /> Signed) ; '„ ?• -----------------------••------------ Owner <br /> aBY ------ -------------- - ----�- ---------------- ----------------------- Title ---- -------------------- -------------------------- ---- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 2� -- - ------- <br /> APPLICATION ACCEPTED BY = = DATE 7� <br /> BUILDINGPERMIT ISSUED ------ j---------------------------------------------------------------------------------------------- DATE ----------------- ------------------------ <br /> ADDITIONALCOMMENTS ---------'---------------------=---r------------------ --------------------------------------------------------------------------- --------------------------- <br /> � <br /> ----------------------------------------- --- ---- _---------------------------- <br /> -------------------------------------------- <br /> ---------------------- --------- <br /> ------------------------------------------- --- -- ---- - <br /> r----------------------------------------------------------------------------------- ---------- <br /> IFinal Inspection by: ---------- " ------------------------------------------------------------------------ ,Date ----------- <br /> SAN <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />