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FCR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> -'-------- -- {--0-------------------- <br /> ,/� ` -------------------------- (Complete in Triplicate) <br />------------------'-1�-- This Permit Expires 1 Year From Date Issued Date Issued <br />--------------------------------------------- <br /> Application hereby <br /> no the San complianceJoaquin Local Health tinstall <br /> described. Thisapplication made in wihCounttyOdinana No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ � / 1 . / Q -------------- ---CENSUS TRACT --------------•----------- <br /> =- � � r -------------Phone .----------------------------------- <br /> Owner's Name ------------- <br /> CityG� �— -------------- - .................. <br /> Address _ � - ` -------- <br /> �G 5 <br /> ---------------------------- -- <br /> Contractor's Name ------5- ------- <br /> ------.License #/l?i' rl Phone <br /> Installation will serve: Residence Z Apartment House,❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> _o �.�-_��S� <br /> Number of living units:.------ Number of bedrooms -___-__Garbage Grinder, ----- Lot Size ------------------ <br /> Water Supply: Public System and name ------------------------------------- ---------•-- <br /> _ ____._____Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ SiltE Clay ❑ Peat❑ Sandy Loam ❑ Clay 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,[ ] Size-----------------------------------.------------ q P <br /> Ca acit _ Type -------------------- Material---------------------- No. Compartments ------- -------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------ •-----•-- <br /> LEACHING LINE [ ] <br /> No. of Lines ------------------------ Length of each line---------------------------- Total_ Length ,-._--------- <br /> 'D' Box ---------.-- Type Filter Material ____________________Depth Filter Material <br /> - <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ------ ----------------- <br /> SEEPAGE PIT [ ] Depth ____ --------------- Diameter ---------------- Number ------ --------------------- Rock Filled Yes Q No 0 <br /> Water Table Depth ------------------------------------------------Rock Size ----------------------------- -- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ____------------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> Septic <br /> _______--_------- ------Septic Tank (Specify Requirements) ---_------------------------------------------------------------------------------- <br /> �� <br /> Disposal Field (Specify Requirements) -� <br /> 7-7--------114-VIL'-C-7----- ------�G? -------5-GsI-- ------------------------------------------------- <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 <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 erformance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become sub' t m 's Compensation laws of California." <br /> r <br /> Signed ------- -- ------ -- -------------------------------------------------------- Owner <br /> ---------------------------- ----------------------------- Title ---------------- <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----W------ --- ------------------------------------------- DATE __ - - <br /> BUILDINGPERMIT ISSUED -------- -------- ------- ------ -----------------------------------------------DATE -------------------- ---------------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------- <br /> --- <br /> ------------------------------ <br /> ------ - --- <br /> - ---- -------------------------=------- <br /> --------- - --- <br /> Date �'1 <br /> `C <br /> --------------------------------------------------------- ------ <br /> Final Inspection by: <br /> - <br /> -------`�--------------- -- -- - - - -------- ------------- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> E. H. 9 1-'b8 Rev. 5M <br /> �o <br />