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FOR OFFICE USE: ,. <br /> --------- APPLICATION'F01 k SANITATION PERMIT a -iii) 1/ ? Z - <br /> (Co.�.- ..��...mplete n�— T <br /> i�_ripl_icate_..__) Permit No---- ---------------- <br /> ---------------------------- <br /> This Permit Expires T Year From Date Issued t Dpte Issued .__- ___ _ ____ _. <br /> .--- q <br /> - - - - - <br /> h 40 , Z- Z8' 7 Z -. <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permit to construct and instal! 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 _ _- a2 --- - --------------- ENSUS TRACT --------_,------------.---- <br /> Owner's Name C G� <br /> Address _!;a_ City <br /> Contractor's Name -_. _ h __ ___.License # g "1 _:_ Phone - '/- <br /> -- <br /> ,11 <br /> Installation will ser , -s <br /> ve: esidenceRApartment House Commercial [ITrailer Court ;Q <br /> Motel ❑Other 1 <br /> Number of'iiihin units:__._ Number of bedrooms ______Garbage-Grinder_,______.dot Size ___- ___ - f <br /> Water Supply:� Pub�F�� ~-�� <br /> lic System and name --------- <br /> '--i' <br /> ------- - Private <br /> ---------- ❑ <br /> Character of soil to a depth of 3 feet�•.Sand'Q Silt❑ Clay Peat❑ Sandy am ❑ Clay Loam [] <br /> - <br /> �� Hardpan 0'~Adobe ❑ Fill Material ------------ If yes `type ---------------.------------ <br /> (Plot <br /> _--_ _ __(Plot plan, showing size of iot,Il location of system in relation to wells,buildings, etcmust be placed on reverse side.) <br /> NEW INSTALLATION: <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ j SEPTIC K; Size-- ,--�' _ ----------- Liquid Depth ------_- <br /> f - <br /> C aci Y Type/Q� Material - ! o. Compartments ___ W <br /> _ P <br /> Distance` to nearest: Well ____ �©--------_---_------_-Foundation 99_____:___ Prop. Line _____ <br /> /� -- ---------- <br /> LEACHING LINE [ j No. of Lines /--- Length of etch line`_"/-_`_/`e otal Length _✓�_ (4_____-`--- -_� <br /> t�_ r <br /> 'D' Box 1_---,l--- Type Filter Material ___/)�Depth Filter-Material-'-4--40'-~--_____.::: <br /> Distance. to nearest: Well __Q___________ Foundation --- <br /> I --- _ Property Line. __ <br /> r} I <br /> SEEPAGE PITp _ ____----___ _ <br /> IN ameter ____________-__ Number Rock Filled Yes '[] No i❑ <br /> Water Table Depth ------------------------------------------ '� <br /> oc <br /> 1 P �--�:--Rk Size -------------------------------- <br /> Distance to nearest: Well <br /> ,,__-Foundation ---------------------_------------------ Prop, Line ----- ------------­-- <br /> REPAIR/ADDITION <br /> __--------• --REPAIRJADDiTION[Prev. Sanitation Permit# -------- -------------------- ----------- Date ------ <br /> ---------------I-------- ---Septic Tank (Specify Requirements} ------------------------------------------------------------------------------------------------- <br /> ____-- ------•---•-_-.------------------------ <br /> . (S <br /> Disposal field- (Specify Requirements) --_-_------- / <br /> ------------------•---------•--------- ---:--- -- ----------------------- d <br /> - ------ ---------------------- <br /> ----- ''' -------------------- <br /> ---------- <br /> -==---------- ---- --------- - ---------•------------------------- <br /> (Dra:w existing,an _ i <br /> ------------ <br /> 7 �'d required addition on reverse side) _ <br /> I hereby certify,that I have prepared this application and that the work will be done in accord) cel with San Joaquin <br /> qu n , <br /> County Ordinances, State Laws, and Rules and Regulptlons of the San Joaquin Local Health Disiri"d. Home owner or licen- <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 j <br /> as to become subject to Workma "`s Compensation Xlatvstiof California," <br /> Signed ----------t �L. { i ' <br /> --------- ----- - ------------------------------------ ' Owner <br /> L_____________ <br /> f it <br /> B '' ` Title <br /> y ----------------------- <br /> 1[If'o than own D <br /> i IM FOR DEPARTMENT USE ONLY <br /> I � o- e <br /> APPLICATION ACCEPTED BY__ f I ------------------ DATE ,�_�.Q ----.- _ <br /> BUILDING PERMIT ISSUED =i-------------------------- -- t- ] --------------DATE ' = <br /> ADDITIONAL COMMENTS -----------!IE i g --------- <br /> I ----------- ---- ------------------------------ ': <br /> d i l 1 i <br /> -f i - --- --- <br /> t <br /> r f l it a ( -------------- -------------- <br /> --------------------------------------------------- <br /> t- -- - ----------------------------------------------------------------------------------------------- - <br /> Final Inspection by: ----- ` - Date <br /> `- -= ------------------ <br /> ------------- - --------------------------------------- -- <br /> a SAN JOA;QU14 LOCAL HEALTH DISTRICT <br /> { II t <br /> { <br /> E._H. 9 1-'6$ Rev. 5M Com, <br />