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FOR OFFICE USE: Q rAPPLICATION FOR SANITATION . ERM T <br /> Permit No. .....................7- 3 <br /> ...._ ...n -. k i <br /> (Complete In Trlplicatel f F <br /> y _ _ -77 <br /> r <br /> This Permit Expires I Year From Dab Issued <br /> V Date Issued -21-'-3, . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constrict and install the work herein n <br /> described. This>application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulationse <br /> JOB ADDRESS/LOCATION ........... ....... ..... .y.....a......................CENSUS TRACT .......3�p.....f..... <br /> Owner's Name ........................ .........................-.......................................................Phone . r4... ........ ...... <br /> address. ...................... ------ --•..--•............................. City .5;r................................._......_ ...... <br /> Contractor's Name .:..-.. ./z&e:. U.. _ ............... ...•...............License# � r Phare .`. - <br /> Installotion will serves Residence Apartment House❑Comrrierclal- rall r-Court-❑ <br /> . -..-...._ -. �- Motel.0 Other- _.- �. ............. <br /> - <br /> Number of living units:... Number of bedrooms ......Garbage Grinder ............ Lot Size. .. 1. ...... : ..........:•... <br /> , <br /> Water Supply: Public System and name ........................................................—..................................................Private e <br /> Character of soil too depth of 3 feet: Sand E3 Silt❑ Clay ❑ Peat❑ Sandy Loam❑ day Loom i <br /> Hardpan❑ Adobe❑ Fill Material ............if yes.type......................... <br /> i <br /> L <br /> Plot plan, showing size of Tat, location of system in relation to wells, buildings, etc. must be placed an reverse side. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,l ; <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I } Sise..i�? ........... Liquid Depth ......,................ti, <br /> capacity ----.... Tylm f `''4.�rMatedal......... No. Compartments •...... ! ..�.Distance 'to nearest: Well' Foundation...... . . .. .............. -................._...-Prep. L1ne ............. _.LEACHING LINE [ } No. of Lines ......................... Length of each line............................ Total Length ....._..........::...'D' Box :.:.. Type Filter Material ....................DepthFilter Mabrlal ...._...................:................Distance to nearest.Well...................... Foundation ..........:............. P►operty Llne .. .............. <br /> ... . . <br /> f <br /> SEEPAGE,PIT [ } Depth .................... 'Diameter ..........r...—Number ............................ Rock-filled Yes ❑ No ❑ s <br /> Water Table Depth �.' .Rock Size #'............................[ ' <br /> Distance to nearestt Well ............ ...'....Foundation.....----........... Prop. Line + ......... •. ..... <br /> REPAIR/ADDITION IPrev. Sanitation Permli# •.--..........-.......' ...� . Ddid .. :.'� "..� .:-: -..I-), ,. <br /> Septic Tank'(Specify Requirements) ......................................................� ',,�: ....1....:.... _......... .3 ................ <br /> s ©tsoosbl'Fieid,.(Specify Requirements) ...........{ .......................... �.........:.:... i <br /> . _ ,1 _ I <br /> ff <br /> ..................L . ire 1 <br /> ................................. <br /> .. _ <br /> existing and required,a'ddition,bn_reverse side) f <br /> Lherehycartify that_ I have prepared tfiis, application:and'That the work will be done In actordanto with Son Joaquin � <br /> County.Ordinances, State,Laws, and Rules and Regulations of the San Joaquin Local Htiallh District:Hotnti owner <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which 14permit is issued, I shall net employ any person In such manner <br /> ds to'become,subject to orkman's Compensation laws of California." <br /> S.gn't d ........... ... i. '.. `' ...... Owner <br /> _ ........................... <br /> _:. <br /> By ...............Y--..;....-----------•----....----•-•---------------------------•--------••-----•----- Title <br /> (If other than owner) ; <br /> I i <br /> FOR DEPARTMENT USE ONLY <br /> _ .............. DATE .....3--n. <br /> APPLICATION ACCEPTED BY ........................ <br /> BUILDING PERMIT ISSUED ........................ ......._.... . <br /> .......... ........ .......:.: ... ..............DATE,... �:�....... <br /> . <br /> .-. .... .... <br /> ADDITIONAL COMMENTS . ........-..•............ <br /> ...........:....................... ......................................... ..........................----•-----......... ...... .....-..........................I----.-------....- <br /> ........................ ----------.............................. .... .-.-....... <br /> _ .... <br /> ............................. <br /> .Final Ins ection b Date ... . . <br /> ..................•--.---.. e ..... <br /> 13 2 1-6Fi to <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M r <br /> 3 <br />