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FOR OFFICE USE: APPLIeATION FOR SANITATION PERMIT dd <br /> 7%is ofacs _g� a/A ftJref p Permit No. <br /> --- - ----------- <br /> 9 ?D r T 4A1- roWK (Complete in Triplicate) <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 Cou ty Ordi once No. 549 and existing Rules and Regulations. <br /> --- - ->- L -CENSUS TRACT -------------•--••-------- <br /> JOB ADDRESS/LOCA ION <br /> Owner"s Name -------------- `- e <br /> Address ----------------------- ---- ----;?�-t - ------ ------ ------------- City --- _ <br /> Contractor's Name ------ ---- - --------.License #c -�_� --- Phone _ --j-- <br /> -------------------------- <br /> } �pcirtment <br /> Installation will serve: Residence - House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other --------------------------- ---------------- xx <br /> Number of living units:-----I-- --- Number of bedrooms 2' Grinder ___ Lot Size - -� ____r1_ �--?------------ <br /> Water supply: Public System and name ------------------------------------------------------------------ - --------------r------ ---------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ill 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 <br /> p seepage pit permitted if public sewerl&available within 200 feet,) <br /> PACKAGE TREATMENT I ] SEPTIC TANk'( ize---_____ ____ t --_.__ _______ Liquid Depth ___ �.------.-•.-- <br /> No. Compartments <br /> .� Capacity �- --------- Type �----------- -- Material------------ p -r�---'-=--- <br /> Distance to nearest., Well __________________________Foundation -----/-------- ____ Prop. Line ... �_l____----_ <br /> f <br /> LEACHING LINE No. of Lines --r -----'----_- g -- --_ Total Len �� <br /> ------ Length o eac fine_ Length ______2----------------- <br /> 1 iL( <br /> 'D' Box ___ . __.:_ Type Filter Material;-._ ______.____Depth Filter .Material ___2 -.______________________________ <br /> Distance t nearest: Well __ __�_____�___'_ Foundation ___l--_!�_�__________ Property Line __`._.J.___._.__... <br /> i <br /> SEEPAGE PIT Depth __-_ _____ Diametew. _____---- Rock �o Filled Yes c <br /> Water Tale Depth -------�-l---'_�-..?_- �-r-_._� <br /> -��__�______ Number _ <br /> ----------------- - - Rock Size ---�/�.�-�---------- <br /> ( . :. <br /> Distance to nearest: Well______________________-.-..Foundation _ _ __�_).---. Prop: Line$_____-..__._-__._- - <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ------------------------- <br /> Septic <br /> _______________________Septic Tank {Specify Requirements) -------- --------------------------------------------------------------------------------------- ='------------------------------ <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------ -------------------- ----------------------------------------------------------------------------------------------------------------------- <br /> {Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 Workman's Compensation laws of California." <br /> Signed --------------------------- --------------------------------- Owner <br /> 7 ------------- Title ------- �� --------------------- <br /> BY ------------------------------------ ----- - --- ----L�" ----- --_. <br /> (If other than own r) ' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.- --- _-- - _ --_-- ----------------- -------------DATE ._tea__- --- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------- - ----- --------------------------------------DATE --------------•-"-----=---------------------- <br /> ADDITIONALCOMMENTS ------------------------------------ ---------------------------•----------------------------------------------------------------- --------------------------- <br /> --------------------------------- ------------------------------ -------- ------------------------------------------------------- ------------------------------- ------ ------------------------------- <br /> - -------- ---- --------------------------------- ----------- ---- ---- --- -------------------------------------- ----------- -------------------- ------------------------------------------------ <br /> -------------------------------------------- ---------- --- - -- --- -- --- --------- <br /> Final Inspection by: ------ Date <br /> --�-/- ------ <br /> ----- <br /> SAN JOAQUI LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M Ml� <br />