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FOR OFFICE USE: <br /> APPLICATION- FOR SANITATION PERMIT 7' '7 <br /> Permit No. _ <br /> (Complete in Triplicate) <br /> ............... <br /> ---------------­ t-rx <br /> --------------V---•- This Permit Expires I Year From Dow Issued Dote 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 ma I do in compliance with County Ordinance No. 5W4191an existing,Rules and Regulations..' <br /> JOB ADDRESS/LOC .....CENSUS TRACT .......................... <br /> Owner's Name ......... Phone <br /> ...... ............................. <br /> F............ ......................... .......................... <br /> c C,................ ----------- <br /> Address ... ... ........ ("A9, .... ... <br /> License #yl <br /> --- ....................I....... <br /> Aa� 41-- <br /> s Name ------ - ------I <br /> Contractor' --- ---------- <br /> ............................. <br /> Installation will serve. Residence(EErApartrrient House 0 Commercial OTroller Court 0 <br /> Motel C]Other ... N111111, <br /> i­'............ <br /> — ........117� <br /> Number of living units:_...... Number of bedrooms ...�Oafbage Griricler4.../...... Lot Size ........................... <br /> Water Supply: Public System and name ........ .................... .if I J '2� %S <br /> ............... ................... ...Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay C3 Peat C]\� Sandy Loom JJ Clay Loan. ❑ <br /> RHardpan El AdobeFill Material . 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 permiffed If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK ize...... G . Liquid-Depth ..!7`'... ... ......_ <br /> �;_ .... .............. <br /> Capacity Typeateriole:.................._5 o. Compartment's ...................... <br /> Distance to nearest: %&ell ...... ..............:.Foundation ......... Prop. Line .............. <br /> ING LINE ----------- Length <br /> LEACH No. of Lines of eci�h line...... . ................ Total length ...�;... ............. <br /> I le <br /> 'D' Box e.... ----- Type ............ ............... <br /> T Filter Material Alk,_Depth Filter Material <br /> ............. Property ........................ <br /> istance to nearest- Well Folunclation Line <br /> SEEPAGE PIT tr�Depth ---:�7 _/______1. Diameter Number ....../.................. Rock Filled Yes No <br /> Water Table Def_rpthl...-----•--21)-------I .. -------Rock Size -.2....... <br /> ----------- ---- <br /> 0 l` Line ......... <br /> ....................foundation ---P ...... Prop, <br /> Distance to:nearest:-W611_=��o <br /> REPAIR/ADDITION(Prev. Sanitation Perrnit,# ....................................... .... Date......... ..................... <br /> Septic Tank (Specify Requirements) ------- ....... .................. ........................I..................1,........­­_­........................ <br /> Disposal Field (Specify Requirements) ...._.f-•--• ....... .........................w--------­......... ............. <br /> -----------------I--------------------------------------------------I-----_-_-_-X- <br /> - e Z --- - <br /> ... .........--•.._..-- ------------­--------I............................................... <br /> ...... <br /> -----------------------­ --- . ...........I . ......... . ............ ................. .......... <br /> (Draw existing an <br /> required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in ac;raidanco with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquirw4oco1 Health,District. Home owner or licom <br /> sed agents signature certifies the following: It 4 <br /> "I certify that in the performance of the work for which this permit is issued;l,%hall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .... ------------------- -------- <br /> ------------ ........................... Owner <br /> By ............................. <br /> ---------- ----- litle ---- --- <br /> __1 .-- . ­­............................. ------------ <br /> (If OtM n�wn e r) <br /> A-I <br /> FOR DEPARTMENT USE ONLY,!Y' <br /> APPLICATION ACCEPTED By .... ... -------- <br /> ----------------- DATE ... <br /> BUILDINGPERMIT ISSUED _------- ---- ---------------­---------- ------------- ------- -----------­­1--------DATE .........--......---........_.-...-------- <br /> 1 <br /> ...... .......I................. <br /> ADDITIONAL COMMENTS -------------------------- -------------------------------- <br /> ............ ----------- -------:-------­------I------------------------------------- ...... ........I.................. ............­.......................................... <br /> . I , - :-, 7: 6................. ................1­ 111--------------- ................................. <br /> ------------ .......... ....... <br /> ........... . <br /> ----------------------- <br /> ----- - ------- -- - - --- ------- ------- <br /> Final Inspection by.?"-: -- ----- _ -------- ........................... .............Date <br /> EH 13 2h 1-68. '.1, v.V5H SAN JO UIN LOCAL -AEALTH DISTRICT .. .... <br /> 8/7h 3M <br />