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EOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> - -------------------- --------- ---------------------- <br /> - <br /> (Complete in Triplicate) <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 per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> �fj .� <br /> JOB ADDRESS/LOCATIO f-_ - -----� ------------------------ ------CENSUS TRACT ------------ ------------ <br /> Owner's Name ----------- - •I---------•----------------- --------=----- <br /> - ------------Phone ------------------------------------ <br /> Address ---- <br /> --------- ----2--- ---------- - --'--------City ----- -'&7 ' -------------------- •----------------------- <br /> a 'Contractor's Name ------- ----�--- - ? ----------- -License <br /> # d Phone -------------------_--------- <br /> Installation will serve: Residence t Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units_]------- Number of bedrooms -----I------Garbage Grinder ------------ Lot Size ---------------------------- -------------- <br /> Water Supply: Public System and name ------------------------------------------------------------- ------------------------------------- ----------Private [ <br /> Character of soil to a depth of 3 feet: Sand'❑ Sitt❑ 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 [ I SEPTIC TANK'f ] Size---------------------------------------- Liquid Depth -----_------------------- <br /> Capacity - ----------------- Type -------------------- Material---------------------- No. Compartments ------------- -------- <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 -------------.--------------------1 <br /> SepticTank (Specify Requirements) ----------------------------- ------------------------------------------------- ----------------------------------------------------------•-- <br /> Dis osal Field (Specify Requirements) ---- Q--- ----- _ " ----- <br /> ---------------- <br /> ---- <br /> -- --- <br /> / <br /> ----------------I•----- <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 /> ---------------- - <br /> /' .�--Title ---------------------------------- ------ ------------------------------ <br /> --------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> Z <br /> APPLICATION ACCEPTED BY ---- ------------------------------------------------------------ DATE / --- ------------ <br /> BUILDINGPERMIT ISSUED --------------------------------------- ----------------------- ---------------------- --------------DATE - ---------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------- ------------------------ ------------------------------------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------ ---------------------------------------------------------- <br /> -------- --------------- <br /> Final Inspection by: ------ --------------- --- -- - -- ------------------- ------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />