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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------------- ---------------- - - <br /> (Complete in Triplicate) Permit No. <br /> ---- - - ------- -------------------------------------- <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 Count Ordinance jNoo.. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---------- ------- f- ---- - ---- -- ---,E"- ----------------------CENSUS TRACT ----- -------------------- <br /> Owner's Name ------- ---- ----•--- ---- -- --------- - - - ------Phone ------------------------------------ <br /> --- ---I- - - ------------- - - ---------------------------------------------- <br /> Address ------�--� ---- ----- --------- -- ------------ - -------- -----------CitY ---------------- -- ----- -- <br /> Contractor's Name ------- - - - - --- - ----•--- -- - - License # ---- Phone -------------••--------------- <br /> Installation will serve: Residence [Apartment House[] Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units------------- Number of bedrooms ----7"'_--Garbage Grinder ------------ Lot Size ---_-------.------------_---_-------.---- <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 ❑ <br /> Hardpan ❑ Adobe.E] 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.)µ' <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -----------------.-------- [n <br /> Capacity -------------------- Type -------------------- Material------- -- No. Compartments ------•---------_--_ GI <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 D <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ------_--------------------------------Foundation -------------------- Prop. Line ....----.............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) --------------- --------------------------------------------------------------------------------------------•---------------------------- <br /> Disposal Field (Specify Requirements) --- � 9111,12- ------------------------------ <br /> ------------------5------ ------ •--------------------------------------------------------------------------------------------- <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, 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 /> By ---- ---------- ---------------------------------j?a-- Title ----------------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- -- - - - - - ------------------------------------------------------------------------. DATE -. '----------------- <br /> BUILDING PERMIT ISSUED --------------------- ------ ------------------- -------DATE ---- -------------------------- ----------- <br /> - ------------------------ ---------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - ------------ <br /> -------------------------------- ------------------------------------------------------------------------------ - <br /> Final Inspection by: ---- -----------------------------•- ----� <br /> -------------------------------------Date -- - --------- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />