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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �d <br /> ----- -- ----------------- -- - <br /> ----- - Permit No. -------� ------ <br /> (Complete in Triplicate) <br /> .---_______ This Permit Expires 1 Year From Date Issued Date Issued <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 Nom. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI r RC2-- °---- -- GC010 --.._.CENSUS TRACT ----- -------------------- <br /> Owner's Nam -- -- -- ' --------- ------------------------------------------- Phone------------------------------------ <br /> Address -------- - ------ G j���= <f� City -------------------------------------- <br /> Contractor's Name .._- __ __ __ - .- - <br /> License # -3 Phone ------------------------------ <br /> Installation will serve: Residence Apartmentr House Com - rcial:❑Trailer Court ❑ <br /> Motel ❑ Other ---- -__ ' <br /> Number of living units:---- Number of bedrooms !?;�-------Garbage Grinder,.___--____._ Lot-Size-----------------------_-__-_._---_---._---. <br /> Water Supply: Public System and name ---------------------------------------------- --------------------------------------------------------------Private [J <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt El CI( Peat F] 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__ ! _� _ _�_X_ -`._-_.__...._ Liquid Depth .... _.__�_..------__- <br /> ,,� , <br /> Capacity t�a_- _ Typ�._____ Material__@-�k-�..:`^�.No. Compartments ,�.�___ <br /> Distance to near t: Well -----_--__ '_.___________._____Foundption _.l�? a,.._______ Prop. Line __S_`_______ J <br /> LEACHING LINE e No. of Lines _-____�__--_ '' <br /> [ -----_._.-- Length of.each line------�f-Q©-------------- Total Length ---�_.»_Q__ _----_-__-- 0 <br /> t _ _ <br /> D' Box ___-__--- Type Filter Material <br /> -------Depth Filter Material __f� '________________________________-_ <br /> r Distance to nearest: Well ___Ja------------- Foundation ._10_�.._ <br /> � I - Property Line. --�--- -------------- <br /> R- <br /> ------=---- <br /> ar 4 <br /> SEEPAGE PIT Depth 11 p_ r __ _, _�° Number _____.._ ___-.-__..__ Rock Filled Yes ® No C <br /> [ p f ------ - <br /> Water Table Depth iamefie�' ---- , !` <br /> - --._Rock Size ----- - ------------------------ <br /> Distance <br /> -----��---------- <br /> 1 r , <br /> Distance to nearest: Well --------- -C2____------------------Foundation ---- ------- Prop. Line __S.__...--.--_-.- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------_---------------------------:-------. Date _--_--_-_---___-__-____-_--_-_-_-) <br /> SepticTank (Specify Requirements) ----------- ---------------------------------------------------------------------------------:---------- - ------------------- ----.- <br /> Disposal Field {Specify Requirements) ------------------------------------------------------------ <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 <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 performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---- --------------------------------- ------------------- Owner <br /> 4 . <br /> BY: ----------- Title ---- ---------------- -- - <br /> -- ------ --:------- <br /> --------------- <br /> {lf other than owner} <br /> ,g FOR DEPARTMENT USE ONLY ) <br /> APPLICATION ACCEPTED BY _ `-tt. --------. DATE f-j-------------------- <br /> BUILDINGPERMIT ISSUED -------------------------------------- --------------------------------------------------- ---- ---- ----DATE -------------------------------------------ADDITIONAL COMMENTS ------ ------ ---- ---------------------------------------------- - - <br /> ------------------------------------------ <br /> ------------------------------------------------ -�----------------------- ------------------------------------------ -------------------------------------- -----------------•----- <br /> --------------------------------------- <br /> ------------------------------------------------------- ---------- ------- t <br /> Final Inspection b <br /> --------------------------.Date __ - '�-.: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />