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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---------------- Permit No. <br /> (Complete in Triplicate) <br /> ----------------- ----------------------- <br /> Date Issued <br /> ------ <br /> This This Permit Expires 1 Year From Date Issued f <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 /> qX <br /> JOB ADDRESS/LOCATION . - C - ------ --- -------------------------- ---------CENSUS TRACT ------------------- ------ <br /> Owner's Name - - ----------- --- = Phone <br /> Address ----------------- -------------------------- City -----------------------------------------------------------------_.......-- <br /> Contractor's Name - -------- -- ---------------- ---------------------------------License # ---------:-------------- Phone ------- -------------•-.---•-- <br /> Installation will serve: i Residence ❑ Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑ Other -------------------------------------------- Z4 of living units:.--J-------- Number of bedrooms ___-----___Garbage Grinder ------------ Lot Size _--� --- ---------------- <br /> Water Supply: Public Syste and name -------------------- -------------- Private <br /> Character of soil to a depth`of 3 feet: Sand❑ Silt❑ Clay [:] Peat El Sandy Loam'; Clay Loam 0 <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type ---------------------------- <br /> C <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse4side.) <br /> NEW INSTALLATION: {N} septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> .Ca <br /> ;l -------------------- 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 /> i <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 El No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size ---- --------------------------- <br /> Di I <br /> to nearest: Well ----------------------------------------Foundation ---------------.---- Prop. Line ...................-•- <br /> REPAIAaDDITION Prev. Sanitation Permit# --------------.-___- ------ Date ---------------------------------- <br /> Septic n Specify Requirements) ----------------- i -- ---- --- ----- •---------- - ------- •-------- <br /> Disposal Field (Specify Requirements) ---01ki .-----�j�----- - <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------- -------------------------------------------------------------------------------- - ---------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 ha 4e prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, StateiLaws, 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 perfairmance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as t com su ct to Work _ ' ensation laws of California." <br /> 7 <br /> -4� <br /> Signed -- - ---- ------------ - - -- 4 <br /> Owner <br /> � � <br /> -----------------_�-- ---------- ----- --------------------------------- Title --------------- ----- ----------------------------- -------------------- <br /> BY - - <br /> (If other than owner) <br /> 1 11 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ---------------------- -------------------------------- <br /> ------- ------ ---. DATE ----- ------------------------------------ <br /> BUILDBUILDING ---------- - <br /> ING PERMIT ISSUED ------------ ------------------------------- --- ----- ------------------ ---------- ---DATE -------- ---------------------------------- <br /> ADDITIONALCOMMENTSI- ---------------------------------------------------------------I--------- ------------- --------------------------------------------------•--- •----------- <br /> ------------ ---------------- ---------------------------- -------------------------- --------•-------------------------------------------------------------------------- -------- <br /> ----------- <br /> ---------------------------------------- --� ---------------------------------•------------------- <br /> --------------------------------- --- - <br /> --------- ------------------ ---- <br /> Final Inspection by: -__ ---Date __---- �-�--�rJ--- ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />