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3 : 7vP►�- <br /> FOR OFFICE USE, APPLICATION FOR SANITATION PERMITPermit No: - -TZ- - P��-7 <br /> - <br /> --------- ------------------------------------------- - - - <br /> (Complete in Triplicate) <br /> --------------- ------------------------------------- g i <br /> x This Permit Exl3ires 1 Year From Date Issued <br /> Date Issued --- -------- <br /> .t-. <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 -_�-- ------- .-- _ fff -`' --CENSUS TRACT _-------------____________ <br /> - -------------- - <br /> Owner's Name --- -- -- S � Phone <br /> . .- <br /> Address t f City --- �` I <br /> i, -- -- - - .- <br /> R' = _.License # � Phone = -r�� <br /> Name ------ -------- <br /> Contractor's - L - .� <br /> Installation will serve: Residence- partment House❑ Commercial :E--]Trailer Court i❑ <br /> Motel ❑Other •----- <br /> .� �/Z ' <br /> Number of living units:------------ Number of bedrooms Garbage GrinderVA*--- Lot Size _ ___--____ :_Water Supply: Public System and name ----------------------•--------------- ---------- -------_ --•--------- Private` <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt-] Clay ❑ Peat' ,Sandy Loam ❑ Clay Loam ❑ # <br /> Hardpan ❑ Adobe' Fill Material 4.2 If yes,type ____________________________ <br /> � 4 J <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. mustbe placed on reverse side.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if p blit_ sewer is available within 200 feet) w <br /> _.- Li uid De th __ ------- <br /> PACKAGE TREATMENT [ � SEPTIC TANK pe------- ___X - �- q ` P <br /> 4 <br /> TYp� <br /> ____-- rtm <br /> Materia ---_ 'v� -t `�7a. Com ------ .�---•--• N ' <br /> CapacrtY '`` <br /> _Foundation ----A -----. Pro Line "" - _---••--. <br /> LEACHING LINE NoDis. ofLines nce to nearest: Wei L�gth of each line_.__ - otalgi ' Length ,,�_ -_.•-------------- <br /> 'D' BoxKearest: <br /> Type Filter Material .- 7r_--_____ Depth Filter Material--. _ _ = .____-_;_.-.-------.......__-- <br /> 1 Pro r Line _t. __ . _....---• t <br /> Distance Well __- Foundation j___� �_____.. p ty f <br /> r° ..-`�_---____ Rock Filled Yes (��0 1❑ <br /> SEEPAGE PIT [ Depth ..v Diameter, _ _______ Number --------- <br /> Water Table Depth, '7_4�% ----------- Rock Size Ik-1----------- --:------ r <br /> Distance to nearest Well --------r._­t-----------------------Foundation __f -------- -- Prop. Line ......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...._% ---------------- --------------------- Date --------------------------- ------ G' <br /> Septic Tank (Specify Requirements) ------------------- --- -------------------- -----------•------------•--------------------------------- <br /> Disposal Field (Specify Requirements) --------- , <br /> ------------------------------------------------------------------------------------- <br /> + -- <br /> ----------- ------------------------------------ ---------------------------------"'"------- ------------------------------------------------------------------- ------------------------- <br /> (Draw existing and required addition on reverse side) =r <br /> I hereby certify that I have prepared 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 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 <br /> as to become subject to Workman's Compensation laws of California." � ° <br /> Signed -- --------------------•---- ------------------ -------------------- Owner 1[ <br /> --------------- <br /> BY ---------- - Title -- E. Ls� c F <br /> (If other an wner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- ---------------- ----------------------------- DATE --- <br /> - ----------------- <br /> BUILDING PERMIT ISSUED - DATE-------- ---------------------- -------- <br /> ---- <br /> L <br /> ADDITIONALCOMMENTS ------------------------------------------------- -•------------------•-- ------------------------------------------------------------------------------------ <br /> - --- - CP-- -------- <br /> ------ --- - -------------------------------------------------------------- ---------------------------------------------- - <br /> W��..�- .-.�-..- --------------------------------.. ___ ._- _ F-_ <br /> Final Inspection by:- --- ------------------------- -----"--- - .---------------------------------. - Date - S=-' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. '" i r <br />