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rUK UrrK-t use: (APPLICATION F SANITATION PERM <br /> ------- - ------ Permit No. G- <br /> (Con,C-' :in Triplicate) <br /> - -- -------------- <br /> Date Issued . ..._.0 <br /> ------------ ----------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby madeto the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations- <br /> ------------------- <br /> egulations: <br /> JOB ADDRESS/LOCATJON ---�f- -- ----- --- NSl1S TRACT _=1--` .----•---•_ <br /> " =s <br /> -% --- ----- ----------------- ---E--Phone _ _ N,f f - <br /> Owner s Name --- �'� - ---------!--1✓---; Y <br /> Address ? f . . �, ----------•--------------------------------•------ <br /> City , <br /> Contractor's Name -----1` =_<_::_' ^-----------------------------------------------------------------.License# -----k----------------- Phone ----------------------------- <br /> Installation will serve: Residence [Apartment House Commercial flTrailet Court 0 <br /> Motel ❑Other ------------------ -------------------- <br /> E Number of living units:--------- Number of bedrooms .___�'_-__Garbage Grinder ---------.-- Lot Size I------------ -- <br /> FWater Supply: Public System and name -------------------------------- -----------------------------------------------------------------------`----Private El <br /> Character of soil to a depth of 3 feet: Sand o Silt[] Clay ❑ Peat❑ Sandy Loam 0 Clay Loam <br /> Hardpan] Adobe❑ Fill Material ----- ------ If yes,type ---------------------------- <br /> (Plot pian, 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,) 6 <br /> PACKAGE TREATMENT [ SEPTIC TANK T ] Size------------------------------------------------ Liquid Depth --------------- ------ -9 <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------------- <br /> LEACHING <br /> --------- _:--__LEACHING LINE { j No. of Lines ------------------------ Length of each line---------------------------- Total Length --------------------------- <br /> 'D' <br /> ____.-____-----_ -'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> Distance <br /> ----------------- ----Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---------.------- -:__-- <br /> SEEPAGE PIT { ] Depth -------------------- Diameter ----------------- Number ------------ -------------- Rock. Filled Yes ❑ No . <br /> l Water Table Depth <br /> ------------------------------------------------Ronk Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ---------------.-_-- Prop. Line ------------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------- ------------------------------------ Date ----------------------------------) <br /> E { Septic Tank (Specify Requirements) -------- ------------------------------------------------------------------------- <br /> =' Disposal Field (Specify Requirements) -__ �z=--- ------./��--_-- <br /> -. <br /> ar <br /> I � � <br /> JG <br /> l# -------`-------- --------------------- ------------------------------------------->----------- ------------------------------------------------------------------------------ <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 liven- <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 object to Workman's Compensation laws of California." <br /> s� Signed ------ -- -- - -- -- -- -- -- ------------------------------------ Owner <br /> By ----------------------------------------------------------------------------------------------------- Title ----------- ----------------------------------------------- ---- <br /> + (If other than owner) <br /> FOR .DEPARTMENT USE ONLY t <br /> BtJPDCNGIOERM�C�SSUEDD�Y---------- - 'w.- ---t1R--r---�------------------- -------- -----------------------------------� DATE _�r-`-�'`.-� <br /> --------- <br /> ------------------------------------------------- -------DATE --------------------- -------------------- <br /> ADDITIONALCOMMENTS ---------=----------------------------------------------------------------------------------------------- ----------------------- --------------------------- <br /> f -------------------------------------------•------ �------=-----------=-------------------------- ------------------------------------------------------------------------------------- - -- <br /> f _ <br /> --------------------- <br /> � t <br /> Final Inspection b : ---- -- ��L� - ----------------------------�4 Date -- - --------- <br /> -7- _ <br /> P. Y - ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t" <br /> i E. H. 9 1-'66 Rev. 5M <br />