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t <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �f <br /> Permit Na: <br /> ------ ------------ - ------ ---------- --------- <br /> - <br /> - (Complete in Triplicate) <br /> ------ ------ ------------------------------- <br /> Date Issued <br /> ----------------------------------- --- ----------- <br /> This Permit Expires I Year From Date Issued I <br /> Oo!S,_r ft .-s-r <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- de. in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ----y---�--- r -� '"°� G.t __� __ `- CENSUS TRACT <br /> Owner's Name ._._ - '^' �+! Phone 1. <br /> Address _...- - t --- City ----------------------------------------------- ---- <br /> I <br /> Contractor's Name -. - ----------------------------License # ---------:-------------- Phone ------------------------------- <br /> Installation <br /> --------------------------- -Installation will serve: Residence ❑ Apartment House ❑ Cornmerciaf frailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units------------- Number of bedrooms -__--------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 ❑ 1_ j <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type ----------------------------- W <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 TANKAj Size------'`_t--_I-k---r------------ ------ Liquid Depth --y----------- ------- <br /> Capacity Type/9 _4° ___ Material_A! No. Compartments Z"'.--_-__._-..-_. <br /> Distance to nearest: Well ___470J_J--------------------Foundation ----------- Prop. Line ---j-_____.-------._ <br /> LEACHING LINE [4j No. of Lines __/------------------- Length of each line......�'0-4------- -___ Total Length __ .---_._._---_-.__ <br /> 'D' Box --_�'.--__. Type Filter Material -_ --------Depth Filter Material 1?------------------------------": - <br /> Distance to nearest. Well ------------------------ Foundation --- --------------------- Property Line --------------- <br /> SEEPAGE <br /> SEEPAGE PIT [ ] Depth --.--____ Diameter ---------------- Number ------ --------------------- Rock Filled Yes E] - ❑ <br /> Water Table Depth ------------------------- -- <br /> --------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ------------------------------------- .-Foundation --------- ---------- Prop. Line __._-----_._-__-.----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------------------------ Date -----------------------------------) <br /> Septic Tank (Specify Requirements) -------------------- --- ------------`- -------------------------- <br /> Disposal Field (Specify Requirements) ------------ -- --------------------------------------------------- <br /> ,. --------------------------------------------------------------------------- ------------------------ <br /> -------------------------- --- -- -- <br /> Draw exist-- required addition ------------------ ---------------- --- <br /> ---------------------- <br /> ----------------- ---- - <br /> g and uire <br /> q dition 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 sub' ct to Workma 's Compensation laws of California." <br /> Signed � . :- _�r -�_- Owner <br /> BY ------------------------------------------ --------------------------------------------------------- Title ------ ----------------- - <br /> -- ----------- ------------------------- <br /> (If other than owner) <br /> -FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------------------------------------- DATE _ ' 'D --..------------------ <br /> ::� --------------DATE ----- -- ---------------------------------- <br /> ADDITIONAL <br /> ------------ <br /> BUILDING PERMIT ISSUED -----------------------� � ----------- - ------ <br /> - - ------------ <br /> ADDITIONALCOMMENTS - --- ---- ---------------------------------------------------------------- -------------------- ------------------------------- -------- ------------------ <br /> ------------------ ------ <br /> - <br /> ---- [ <br /> ---------------------_--.--------------------------------�-_--_----_---------_-----------------------------`---------------------------_-------------------- ---_-_---=_�_------"-__- '--___- <br /> --_ -"_ -- --' <br /> Final Inspection by: ---- '� __r-r-*--- ---------.Date - -- �z�------� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />