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FOR OFFICE USE: /f.�l�G��" L��/ <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT GSI/{ E <br /> (Comp P <br /> (Complete in Tri licatei Cyt„+t Permit No.....7,�7.......... <br /> .........I................ ..............-_-.............- This Permit Expires 1 Year From Date Issued Date Issued..�:. . _. 4 <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described, <br /> This application is,made in compliance with County Ordinance No. 549 and existing Rules and Regulations: : <br /> JOB ADDRESS/LOCATION. <br /> ..�J ------------------­---­--- TRACT--------- <br /> -------- --- -- - -•- <br /> Ow.ner-'s,Name....�i6- ..._ f'' �- . :I r- Phone <br /> Address.. ... ............ . . . ----City.......... ............................... --Zip--------------o --- -.- -- <br /> Contractor's Nam ... - � ___ _______ ________License #-��1._�--!_41._—_Phone_q.Q.c)lS_ <br /> Installation will serve: Residence e�Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other—------ ...... ----------- <br /> Number of <br /> --------Numberof living,units:::�Number of-bedrooms .. Gorbage-Grinder :_...._.1ot-Size n J0it--, <br /> Water Supply: Public%System and name ......---.--........... ...... F.... ................. ..................... .............----..--- ------.Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay 0 Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> i Hardpan ❑ Ac1obeX Fill Material If yes, type.......---------------- <br /> (Plat 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 seepagepit permittekd if public sewer is available within 200 feet,) <br /> qo <br /> - t <br /> PACKAGE TREATMENT ` SEPTIC TANK t <br /> I j ( ] Size V -- - --------------------------------- --------Liquid Depth-------------- -.- <br /> ;Capacity ........Type...... .................Mate,-vial--------------------------No. Compartments-------I------- ------ <br /> ;'i! <br /> -t Distance to nearest:Well.. ........................ ..............Foundation.......... . ..............Prop. Line.................. . <br /> LEACHING;LINE ( ]' .No:-of Linesi.......:..................Length of each line............................. Total Length .-. -------- ----------------- <br /> Box-7 Box- .-. .- Type Filter Material.....:....... ......Depth Filter Material--.-- ...----.----- .----.,.-.---.------..........---....-.-. <br /> �r.". , s I <br /> Distance to nearest: Well------------------ ---------F .--..---.._.----.-----------Property --_oundation Pro ert Line -----------...-.--....-.---.--.-- <br /> --- _- <br /> SEEPAGE PITq, ( ] Depth.. ............Diameter...........---------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> kh. Water Table Depth-------------------- ---- . ..-_.Rock Size--..........- - <br /> t Distance to nearest: Well-------------------------•.................Foundation..........................Prop. Line.......------------ -- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----------=----- .........Date.-------:--------.-........................... <br /> } f <br /> Septic'Tanki(Specify Requirementsl ---.. ............. ...:...... . .. ---- - ----.:---------- ...........---. t <br /> c = rz <br /> Disposal Field--(Specify Requirement9 .....--7_(1-•- ------ --- -.. l- <br /> : ..... <br /> - ------ ------- ----------------- --------- -- ----- --------------- <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 County <br /> Ordinances, State Laws, and Rules and Regulations of the ,San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> t <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 as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed - ......... ....... --- .--..----Owne.r <br /> ..................Title -- <br /> (If other than owner) <br /> f FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----.... . .. DATE . �.....- ? "-- --.... <br /> ........... ....... .......... ......... .... <br /> DIVISION OF LAND NUMBER......... ..----DATE....... <br /> ADDITIONALCOMMENTS.,z....................... --------•---------------- ............... --------------------------------- .............. ........... - t <br /> - ---------- -------------- - ------ <br /> ............................................. <br /> ---------------•------• ----......--- ��;� -, ------- <br /> ...- 7� -9 ..- <br /> Final,lnspection b - .... F------•--- .._Data r :..... ..._-.. <br /> EH 13 24; SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV- 4/76 3M <br />