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FOR OFFICE GSE: A <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- ------------------- •--------- ----------- Permit No. <br /> (Complete in Triplicate) <br /> -------=- ------------ <br /> � I Date Issued _����_'_.. • <br /> ----------------------------------------- --------------- This Permit Expires 1 Year From Dafe 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 No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - -- -1_��-- _ ------Z5 CENSUS TRACT _- -_--.- <br /> Owner's Name �- ----- Phone <br /> Z !1/C ►v' j �� ----------------------- <br /> A — <br /> Address _/. ----- = City <br /> Contractor's Name ------ --------------------------------- --------------License # ---------:-------------- Phone --------------------- ------ <br /> Installation will serve: Residencet: partment House❑ Commercial :❑Trailer Court <br /> Motel ❑ Other'ti;____'----------------------------------- <br /> Number of living units:_)-.-__.-. Number of bedrooms - Grinder __�/0__ Lot Size <br /> _. - ----• <br /> WaterSupply: Public and <br /> - Private <br /> ---------- <br /> Character of soto depth of 3eet: Sartd ❑} <br /> Silt Clay Peat Sandy Loam Clay'Laam ,❑ <br /> Hard an ,dobe ❑ C.Fill Material - - - -- If yes,type ---------------------------- <br /> p ❑ <br /> (Plot plan, showing size of lot, location of 'system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> - 11NEW INSTALLATION: (No septic tank orfse6page-pit-permitted-if-public sewer is available within 200 feet,) O <br /> PACKAGE TREATMENT { J 1SEPTIC TANKI I,' Size-------------------•---------------_---- ------ Liquid Depth ---------_--------- .----- <br /> Cisa p�a9c�i_t.�._. , �'------- Type -------------------- Material---- -__._-__-- No. Compartments <br /> ---- •------- ------- <br /> ty 'Distance to .nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- �1 <br /> LEACHING LINE j'] ) Nod of,.Lines Length of each line-______-,--._-------------- Total Length ------------------- -------- <br /> t D B# <br /> ox -------i__.jType Filter Material --------------------Depth Filter Material --------------------•-------------•-.-••---- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------------- <br /> SEEPAGE PIT [ j Depth ------------- <br /> ------ Diameter ________________ Number ---------------------------- Rock Filled Yes E] No <br /> Water Table Depth ---------------- ----------------------=--------Rock Size ---- --------------------------- � <br /> Distance to nearest: Well ----------------------------------------Foundation .------------------- Prop. Line _____.__--______..__.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit�# ------------------------- <br /> ------------------ Date ----------------iI-V 1------------) <br /> Septic Tank (Specify Requirements)!- r------------------------------------------------------- ----------------------------------------------.---.----------------I---------- <br /> Disposal Field (Specify Requirements) _._.,__ � - --- ' - <br /> �� �- I l _ <br /> - , _ `,--yP-= ------ ------- x {----------------------------------------------------------------------------- <br /> ., <br /> -L-- <br /> ------------------------- - ------------ -�---(Draw '-----------existing and re ---------------------� -- ------------------------ -------------------- <br /> required addition on reverse side} <br /> I hereby certify that I have prepgred' 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 agent ignature certifies the following: <br /> "I certif tin the perform e'of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to c e subject to Wor ins pensation laws of California." <br /> Sig d �r±�f r ---------------------- Owner <br /> - Title <br /> (if other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY!----------1 i 4 - ---- -------------------------------- ----------------------------- DATE --------------- -•- --- <br /> BUILDING-PERMIT-ISSUED --- _=-_____-- _--- __-_.:_.:�___.:__-ma=r =-== .-___DATE _ =' <br /> ADDITIONAL COMMENTS -- = ' .... =;'r '; '; - `, `,= ---------------------- ---------- --------------------------- <br /> 4 .. ---------------------------------- ----------------------- --------- ----------------------- <br /> - ----- <br /> - -- <br /> -- ------ - ------------- ---- - <br /> --- . -- = <br /> -- -= - -- -- - -- -- - <br /> Final Ins <br /> -------- <br /> ------ ----- -- <br /> peb - Date - ------------ ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />