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FORLOFFICEE: APPLICATION FOR SANITATION PERMIT -Permit No.-------------------------------- ---- (Complete in Triplicate) <br /> ---------------- p Date Issued- -------------- <br /> This Permit Expires 1 Year From Date issue ,Q� <br /> and <br /> e work <br /> Application is hereby made to�h dean Joaquin compliance <br /> al wiHh Counealth District <br /> Ord Wafor <br /> n a Nomit to const 49 and existing Rulestand hRegulat Regulations.. <br /> described. This application is p i-A "NP+0P <br /> -----------CENSUS TRACT <br /> - - --------- ----- <br /> JOB•ADDRE S/LOCATION - - - --- ---------------- s`i J <br /> • - Phone f <br /> r <br /> Owner's a ---- - <br /> - <br /> --- ----------- Cit) `` <br /> Address C� __ --._7_..-•-- <br /> q '--- - .., <br /> l • a-` 9----- Phone <br /> -------------a <br /> License <br /> Contractor's Name ----- -- - ---- ---.--� "--"---- - <br /> Installation will serve: Residence ❑Apartment House❑ Commercial Trailer Court '❑ <br /> Motel ❑Other.--------------------------- -- ----- <br /> Number of living units------------- Number of bedrooms ---------..-Garbage Grinder - ------ Lot Size ----- ---- <br /> - ' f-'------------- y <br /> % <br /> 6 <br /> - Private <br /> Water Supply: Public System and name --------------_-------------------- ------- - <br /> Character of soil to a depth of 3 feet: i Sand nSilt}] Clay ❑ eft❑ Sandy Loam Clay,loam <br /> El <br /> Hardpan ~AdobeFili Material-; -, ..-- If yesype -�_ <br /> E ` buildings, etc. must be placed on reverse side.) <br /> (Plot plan, showing size of lot, location of'system in relation to wells, <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> 1 I Size------ -- Liquid Depth ---------------- --------- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'f J r <br /> ------ <br /> Capacity:j ` - -- Type -------------------- Material:------ ---------- = No. Compartments ----------- <br /> Distancek to nearest: Well ___________________ <br /> ------ ---_Foundation --------------------- Prop. Line ----------------•----- <br /> ------------------- - -- Len th of each line. ------- ----- ----- Tota! Length ------•--------•------------ <br /> LEACHING LINE [ ] No. of Linesg �a .- <br /> -` Depth Filter Material -.- --------------•-----------•---•-- ` <br /> 'D' Box ------------ Type Filter Material -------------- P '► % � t . 41. <br />` , Property Line <br /> - --- Foundation ------- -------s ------ p ty ---------------•----- -- <br /> f Distance to nearest: Well ___-- ------ - <br /> De th Diameter -----------•---- Number --------=---------- Rock Filled Yes ❑ No i❑ <br /> SEEPAGE PIT [ l P =-: <br /> - - --�----Rock Size ----- -==------------•--- - <br /> Water'Table Depth ----_------ --------------------------- <br /> ,�a. Pro Line . <br /> Distance to nearest: Well ------------------------------- Foundation ---------------- P <br /> I ) <br /> ' - ---•--- �: Date --------------------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit ------------------ a <br /> tc -------------- <br /> Septic Tank (Specify Requirements) ---- -------------- --- y <br /> Disposal Field Specify Requi�ements)� ------------- - <br /> - - - - ------ - - <br /> -------------- ----- - <br /> -------- <br /> _ --- <br /> ------ ------------------------------------- __.-"_.-.__-____. _ ....�. _ _ .�-.•- - <br /> -. -m <br /> (Draw-existing-existingreverse side) - - <br /> gi- <br /> hat the woi� wjil be done in accorace With S <br /> I hereby certify that I have prepared this application <br /> ulatioi+san Joaquin <br /> tof the San Joaquin Local Health D strict nHo e o ner or I cen- <br /> County Ordinances, State Lawsr: and RulesandRe9 <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 b me la'eck to or on's Compensat. laws of California.' r <br /> Owne <br /> Signed _ <br /> Title <br /> (If other than wner) ! <br /> FO DEPARTMENT USE ONLY � f <br /> I f -------- ------------------- DATE ------- `' tri ------- <br /> APPLICATION <br /> 4___ __________________ ________ _ _._-_..._._. <br /> APPLICATION ACCEPTED BY ----- _�-~�-�'- - - _ <br /> .� DATE ------- ---------------------------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------- #-----------: w. -------------- ------------ --------------------------------------------------- <br /> ADDITIONAL COMMENTS ------ - ..--------- -----------------------------,----- - <br /> -----------`---------------------- <br /> - --- -- -- --------------- i <br /> .. -------- / _ ----- <br /> --- - - - - - - - - <br /> ----- ----- <br /> --_--- - ate <br /> -- ----- --- - --- <br /> f' <br /> Final Ins ion by. ��� ;, ; <br /> ' t.SAN JOAQUIN LOCAL HEALTH DISTRICT. _ <br /> E. H. 9 1-'6B Rev. 5M - <br />