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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �� <br /> ---------- --------------------------------- Permit No: ------- --,_._. <br /> (Complete in Triplicate) --- <br /> ---------------------------._.____ __________________. � '/ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the S(an Joaquin Local Health District for a permit 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/LO TION . --- '` ------CENSUS TRACT _�� _�............. <br /> Owner's Name ---------------- ---- ------- ----Phone ---------------------------------- <br /> .., <br /> Address ------ - ''1---�- --- ------ ---- ------ ------ -- --------- --. City -- ---- -- - - --------------------------------------.......... <br /> „-- <br /> Contractor's Name - - ---- ✓----- -- - -------- �---- --- ----- j.License # _/_2.P-3_P71Phone _--_----------------------.--- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial:❑Trailer.Court i❑, <br /> Motel ❑Other --- ' <br /> Number of living units----- .------ Number of bedrooms _____Garbage Grinder _________ Lot Size __�= - r-•___ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private [ r <br />�GharacterTof,soil_to_a depth of 3 feet:; ,.Sand'❑ Silt❑Clay...❑Peat❑ Sandy Loam Y Cla o�am` .❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ____________ If yes,type ____________________________ <br /> (PI'ot 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 permittedI if public sewer is available within 200 feet,) Q <br /> PACKAGE TREATMENT { ] SEPTIC TANK) Sized` _ __, _r�____ ._______ --------- Liquid Depth __ __________________ (' <br /> Capacity _.!_ - __ .:- Type ------------------ Material.-___--- -- No. Compartments _ °.�........... I <br /> Distance to nearest Well ___.______- ----__._--__.____.Foundation__ -__ _______ Prop. Line ______ 5___________ <br /> LEACHING LINE [/] No. of Lines -----/---___----------- Length of each line------- ------------- Total Length __ -............. <br /> 'D' Box ------ Type Filter Material __ __ ----- Depth Filter Material ---/.Ir------* <br /> ___.6.OFoundation ______ _� _ ____, , <br /> _______ ___ Property Line _____ <br /> Distance to nearest: Well _______________ <br /> Depth ----/P......... j ___ Number __.__.___-_______________ Rock Filled Yes No C] <br /> Water Table Depth ---------------7jq------------------.___.....Rock Size -- _ =-•!�--r3Y <br /> Distance to_nearest: Well ________ /JrPZ7....................Foundation ---40---------- Prop. Line ....... <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------- ---------- Date .___-_--__-_______-.______________) <br /> Septic Tank (Specify Requirements) ------------------- ----------------------------- <br /> Disposal Field (Specify Requirements) --------------------------------------------------------------------------- ---- <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 ------------------------------ - l <br /> - <br /> Owner <br /> i <br /> ----- Title '- 'By -------------------------------- <br /> (if <br /> --------------- -(If other than owner) <br /> FOR DEPARTMENT'USE ONLY <br /> APPLICATION ACCEPTED BY ---- rl --------------------------------------------------------- DATE ------------ <br /> BUILDINGPERMIT ISSUED -----------------------------------------------­ -----------------------------------------------------DATE ---------------------------------------- <br /> ADDITIONAL COMMENTS ----------------------------------- ------- <br /> ---------------------------------------------------------------------------------------------------------------------- <br /> ------------ ----------------------------------------------------------------------------------------- --------------------- - -----------------------------------------------------------L--------------- <br /> ----------------------------------- ----------------------7------------------------------------------------------------------ --------------------------------------------------------------------------- <br /> --------- <br /> ---------------- ------------- <br /> - <br /> --- <br /> Final Inspection by: ----- a ---------------- ---------------------------------------------------------Date�z -- ------- - - -- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'S8 Rev. 5M > f <br />