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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ^� <br /> ------------- ---- ------ ---------------- <br /> - -- (Complete in Triplicate] Permit No __________________q <br /> ----- ---------- ------------------------ - ----- �.-/ � •/ <br /> ------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued 6 <br /> Application is,hereby made to the San Joaquin Local Health District for a per 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 /> JOB ADDRESS/LOC TION _�/��---- - ----------------- __--'- -- ------- -------CENSUS TRACT -------------- ----------- <br /> Owner's Name `+� Phone <br /> --- - -------------------- <br /> f So . <br /> Address -----------7-----�----- ,-4-? --- - ------ - --- ---� - � City ---- -- --��-�~� - --• ----- ---------------------------------- <br /> r - L _ <br /> Contractor's Name -- ---- - ----- C ----- .License # / ��` _ Phone <br /> Installation will serve: Residence 94Apartment House❑ Commercial ❑Trailer Court <br /> ' Motel ❑ Other ----------------- -------------------------- <br /> Number of livingunits:------ ___-_ Number of bedrooms <br /> � �____--Garbage Grinder ------------ Lot Size ---------- ----- - ----------- <br /> Water Supply: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 /> (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 200 feet,) (� <br /> PACKAGE: TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ---------_----------,----- Q <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------_---------- <br /> Distance <br /> ------ _--•--•----Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------....:.,___-•- , <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line----------- -------- ------- Total Length ,________________._.--....__ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------------------------.....---------_._ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ <br /> SEEPAGE PIT [ ] Depth ------- Diameter ________________ Number ----- ---------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------•------- <br /> Distance to nearest: Well __________.___________________________Foundation ___________________ Prop. Line -___-______------___ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -_--------------------------------) <br /> h <br /> Septic Tank (Specify Requirements) ---- --- ----------- --------------------------------------------------•-----------:------------- -------------------------•-- , <br /> Disposal Field (Specify Requirements) --------------- - ---------- ---------------------------------------------------------- <br /> o <br /> ----------------------------------------- ------ <br /> -- - -------------- --- --- ---------- <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 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed--------------------- <br /> Owner <br /> ------------------------------ <br /> BY — Title <br /> c+�L <br /> ------------------------------------------------------ <br /> ( other than owner] <br /> FOR DEPARTMENT USE ONLY47 <br /> i <br /> APPLICATION ACCEPTED BY __ } <br /> --------------------------------------------------------------------------------� DATE -�`�-f ------------ <br /> BUILDING PERMIT ISSUED ----------------------------- --------- ---------------------- -------------DATE -------------------------- - <br /> ADDITIONALCOMMENTS ----------------------------- -- --------------------------------------------------------------------------------=--------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------- ------- ----------------------------------------------------------'--- ------ <br /> ------------------ --------------------------------- ------------------------------------------------------------------------------------------------ ----- ------------------- <br /> ------------------------- <br /> Final Inspection by: ____ __ ' _ _ ____ Date/- <br /> --- -- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'S8 Rev. 5M <br />