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FOIL OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br />........ ......................................... <br /> (Complete in Triplicate) <br /> Permit No. ... .......:......... <br />............. .......................................... This Permit Expires 1 Year From Date Issued <br /> 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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC TION . kJ. ..... CENSUS TRACT .......:............. <br /> ..... <br /> Owner's Name ...I ....moi... ...........�.....�........... .. Pito_n_e ... ... ....... <br /> Address .............t....L�.. .. ���...... .... .. .............. City .. .. ... .......... ....:......... <br /> Contractor's Nome ...... ......7 .. . . .. .:.............License # 7-- Phone .............................. <br /> Installation will serve: Residence ❑ Apartment House o C menial ❑Trailer Court 0 <br /> Motel ❑Other ... ... .... ...... <br /> Number of living units:.......... Number of bedrooms :.........Garbage Grinder ............ Lot Size ..........................I................. <br /> Water Supply: Public System and name ............................................................................................ ............Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Cloy ❑ - Pecgt'❑ Sandy Loam [lay 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.f ] Size...............:................................ Liquid Depth .......... <br /> ......... <br /> ....... <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 ........................ i <br /> SEEPAGE PIT ( j Depth Diameter ................ Number .............. Rock Filled Yes ❑ No 0 M <br /> Water Table Depth ................................................Rock Size ................................ �#' . <br /> Distance to nearest: Well Foundation .................... Prop. Line ...................... + <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................} <br /> Septic Tank (Specify Requirements) ................................... ........................ ............................:................................ <br /> _........._....... ' i <br /> Disposal Fiel (Specify Re irements) •--- <br /> ........u.. <br /> ............... ...- --------------•.......................................................................-•-----•-•-•. s <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 Sart Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or liven <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 i <br /> as to become sub)a t to Workman's Compensation laws of California." <br /> Signed ......... .. .... ......... Owner <br /> ............................. <br /> By ................. � . :. - title ..... .................... <br /> .. .�. ........... ... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . .. .. . .. .., DATE ..f. ..:. ................ <br /> BUILDINGPERMIT ISSUED .......................••-•-----.._---....................................---..........DATE ........................................... <br /> ADDITIONALCOMMENTS ...............................................:.............................................................................................................. <br /> ....:......... .............. ..... <br /> ..................................................................................................................................... <br /> .. <br /> Final Inspection byt ...; [�?: ................................... ......................................Date .............. <br /> SAN <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 13 241-'68 Rev. 5M _ _ b _ __ 7/7 <br />