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=OR OFFICE USE: gpp�,ICATION FOR SANITATION PERMS -' t- G'? <br /> Permit No. ..........c_.�_,... <br /> ......... .......• .._................_.. ... (Complete in Triplicates 9- i' <br /> .................................. Date Issued ............... .. <br /> This Permit Expires t Year From Dote issued <br /> Application is hereby made to the Son Joaquin Local Health District Tor o permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No_ Seg and existing Rules and Regviotions: <br /> ,e^ c= •.... . .._......... CENSUS TRACT <br /> JOB ADDRESS/LOCATION _..... � ... _... ---- <br /> ; <br /> �:c Ln.�: i, �'C`. _.... Phone ------_-----------•---•--•.----- <br /> Owner's Name 1:. ..............,. ...- _ <br /> Address .............. •.......... ...... .. ... ._... .--..,..............._ .--•-• ... City ._.a_TL�!S. .:G.!:/_._. ..... ................... <br /> ._. .............................. <br /> nse one --.•....-.._.._.C........ <br /> Contractor s Name ~- <br /> installation will serve- Residence (<partment House[o Commercial 7iiTradw Court 'Cl <br /> Motel ❑ Other ............................................ <br /> ' Garbo Grinder of Size <br /> 1 iT�� <br /> Number of living units;------- -"- Number f bedrooms ��,�— 4e, vat <br /> • _ _ Pri a <br /> Water Suppiy- Public System and name _._.... <br /> Clv <br /> ❑ � <br /> Character of soil to a depth of 3 feet: Sand'Q Silt Cloy � Peat❑ Sandy Loom <br /> ❑ y Loom L <br /> Hardpan —1 Adobe <br /> Fill Material ------------ If yes,type .-------..---------. ------ e <br /> eK. must be pieced on reverse side.) O. <br /> (Plot pion, showing size of lot, location of system in relation to wells, buildings, C <br /> NEW INSTALLATION: (No septic tonk or seepage pit permitted if public sewer is available within 2Q0 feet.) <br /> -// <br /> n Liquid F <br /> ................ <br /> PACKAGE TREATMENT SEPTIC TANK Size.Q - " <br /> C <br /> No. Compartments __f-----.----••-- <br /> p c,_..... Type T fS G cfe Material__..----.- <br /> Capacity j <br /> _,Foundation p. Line _..-.---•------...--•- <br /> Well -•-=-�---...-----•-• Pro <br /> Distance to nearest: -•---•----- <br /> � G ' Total Length _�-----•............... <br /> LEACHING LINE <br /> L } No. of Lines ................... Length of each line f -.... <br /> ' _De th Filter Material Linc -----•--y•^-•--Y----- <br /> 'D' Box ` Type Filter Material _.-----..._._..-- P <br /> Properry <br /> ----•----- <br /> Distance to nearest: Well ._.....__-- Foundation ----------------------- <br /> Numbe^ •------- Rock Filled Yes No <br /> SEEPAGE PIT [ Depth .....•.............. Diameter ------------•-- <br /> ❑ <br /> Water Table Depth ---------------------- ---•------ -•-----Rock Size ---------------­-- ------ \ <br /> Distance ro nearest: Well -----••--•-•-----• <br /> ,Foundation --__.-- Prep. Line -------------•-...- <br /> Date -..--...�-.. ....._._) <br /> ion Permit� -------------- <br /> REPAIR/ADDITION(Prey. Sanitation �.........................•-•- -- <br /> Septic Tank (Specify Requirements) .............................. .•------- -..._.__. .._... .•.•^ •------ __.,..._--------- <br /> DRequirements)isposal Field (Specify q ......... <br /> -•----•...............I.Dr.......--_- ... <br /> --- <br /> -'.'•-"`-"" -"•----"".'."" {Drove existing and required add+•tion on reverse side <br /> 1 hereby certify that I have prepared this appliwtiott and That the work will be dome in ncterdance with San Joaquin <br /> County Ordinances, State Lows. and Rules and Regulations of the Son Joaquin Local Health District- Home owner or licett- <br /> sed agents signature certifies the following: to any person in such manner <br /> '•t certify shot in the performance of the work for which this pern+it is issued, t steal! not e+np Y <br /> as to become subject to Workman's Compensation laws of California." <br /> Owner <br /> Signed ... n tie ........... <br /> By ..,.. ^—......�... <br /> (It other -hon awned <br /> FOR OEPARTME14T USE ONLY <br /> HATE ........... <br /> hr;o,iCATION ACCEPTED 3Y ,-.1.. . - .. ......•...... . ... ........... <br /> DAic . ... ..... .... ..... ........... <br /> -IN�G P`_RM:T ISSUED . . ..... -- ....... ........._ . ............ ..... ..... _..........• ... <br /> 'Dl"•CN:,= COt�1Me\-c • ... ... ........ I. .......... ............. .... ..... .. ..... <br /> .� ...... ................................ ..... ..... ....... .. ........... ...............................I.......... <br /> ....... . <br /> ......... . ............ ..... ..............._.... .... " <br /> . ..Date`! �.�.....:........... .... ... <br /> .................... <br /> . ..... <br /> ''_........ _ <br /> . _. ................ • ............... <br /> V.- <br /> SAN JOAQUIN LOCAL r.7_AL79 7;STRICT <br />