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fOR OFFICE USE: <br /> APPLICAT10hr"FOR(SANITATION PERMIT <br /> ----------------- il <br /> -------- P Permit No.0,- <br /> omplete in Triplicate) <br /> ------------- - --------------------------------- <br /> ----------------------------------- This Permit Expires ] Year From Date Issued Date Issued - -------- <br /> — I <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 complicipce with County Ordinance- No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 7z en <br /> . 6 - n. CENSUS- TRACT ----------------------- <br /> ------------- <br /> r s Name ------------ ------- --.-,Ph on ---------------------- <br /> Owne 10 r/ 510-41 -------------- ----- <br /> - <br /> AddreAddress __/ 117. <br /> ss ------------------- q --- - ------- I Ncity -------------------- <br /> --------- --- <br /> h ­­--------- <br /> io---- -----------License #Idf? _ Phone -- ---- ------ <br /> -7/2 <br /> Contractor's Name 6 <br /> 4-------------------- -- <br /> Installation will serve; 1�Residence 21(p-artment House-E] Commercial []Trailer Court ;E] <br /> Motel E]Other <br /> _ <br /> Number of living units:_._____ Number of,bedro)ms,11�2 Garblge Gr`�i P -- ----)V4-------- <br /> --- ---- r Oer-,x-1---------JL&.1,Size_-Q_ <br /> private <br /> Water Supply: Public System and' name ----------------------------------- - <br /> -- ------- ....V1 ❑ <br /> Character of soil to a depth of 3 feet: Sand'E] Silt E] Clay, El Peat❑ Sandy Loam -E] Clay,Lo m ,[] <br /> 1 Hardpan E] Adobe� Fill Material ------------ If yes,type -------------------1------- <br /> (Plotplan, showing size of lot, location of system in relationito- wells, buildings, etc. must be placed On reverse side.) <br /> V <br /> NEW INSTALLATION: (No sept I i I c tank or seepage pit permittea if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK ZA. _ Liquid Depth <br /> e--- --- ---- <br /> 4- <br /> x-5-------- 7, <br /> Capaci J oD ,Type vrne daV-1 No. Compartments ----------------- <br /> ty� ---------- -- aterial(.1-1- <br /> 6 <br /> Distanceito nearest: Well ---------------a-------------------_______Foundation ------ Prop. Line <br /> A <br /> ---------------- <br /> LEACHING LINE, No. of L�nes ----e�_ -------------- Length 'of each line_7.5- Total Length <br /> 'D' Box!"V49S- Type Filter Material __J�j]_9_4��epth Filter Material ---- ---------------­- <br /> - - -------- <br /> F Foundation Pepperty Line ------ <br /> Distance o nearest: Well ------------------- 0 ion ------------ <br /> SEEPAGE PIT Depth ---------- Diameter 'Number ------JAock Filled Yes No 0 <br /> Water T!O!"ble Depth �------- ------------------- ---------Rock Size ---- -------------------- <br /> li <br /> Distance t�o nearest: Well ------------------------ <br /> ----•---.��Iation -----/ I--- Prop. Line ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __:___________-___--________.I___) <br /> Septic Tank (Specify Requirements) --------------------------------------------------------------------I I <br /> -------- ------------------ - <br /> ------------------------------------------- <br /> DisposalField {Specify Requirements) ----------------------------- •----------------------------- --------- -------- --------------------------- --------------- <br /> -----------------------------------------------------�,!--------------------------------------------------------------------------- -------------------------- ------------------------------------------ <br /> - ---------------------------------------------------- -------------------------------------------------------------------------- -------------------------- --- -------------------------------- <br /> (Draw existing and required addition on reve se side) <br /> I <br /> I hereby certify that I have pre aired this application and that the work will <br /> be done in accordance with Son Joaquin <br /> 0 w]u <br /> County Ordinances, State Laws; and Rules and Regulations of the San Joaquin in Local Health Din <br /> 'Let. Home owner or licen- <br /> sed agents signature certifies the-fallowing: <br /> "I certify that in the performonce�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 /> --------------- ---- - ---- ----------- A/1------------- <br /> By ----------------------------- ----------- <br /> -—--------------- -Title ----- <br /> �(If other tha Vne-r,) <br /> 6 FOR DEPARTMENT USE ONLY <br /> lu-------15?2�sf <br /> APPLICATION ACCEPT BY ---------------------------------------------------- DATE --- <br /> BUILDING PERMIT ISSUED --------------------------------- ---- 1) E <br /> ADDITIONAL COMMENTS ---- <br /> ------------------r------- <br /> - <br /> ----------------- ---- ---- -------------------------- <br /> ----------------------------------------------------- <br /> Final Inspection by.. - ----- / <br /> ---------------------------------------------------------------------- ---------------- <br /> _4-------------------------------------------------------- <br /> - ---------------------------------------------- ----- -------------------------- ------------------- <br /> -------------------- ---- <br /> ----------- <br /> ------------------------------------------------------------Date ------ <br /> ---e <br /> AN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7-'68 Rev. 5m---:Z ., <br />