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FdiR OFFICE USE. <br /> ..,� <br /> ... !310 ........ SAPPLICATION .FOR SANITATION PERMIT Permit.No.7K--.4- f-�_ <br /> -------------_--_---_ .. ..... <br /> (Complete in Triplicate) - : —, I <br />.....................................I..._.._ ....... -W-16-ly I <br /> Date Issued .............. ...... <br /> ....................­­......... ThisP�armit-Explres I Year From Date Issued <br /> ------------- <br /> Application is hereby mode to the Son Joaquin Local Health District for a per'mit to construct and install the work herein I <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations., <br /> JOB ADDRESS/LQqAT16N ... CENSUS S 7TRACT .......... <br /> ....... <br /> Owner's ........ .......... ................. ...........Phone ---..................P..........----. <br /> ..... City' ' ............................... <br /> Address ....V, ....... --------- <br /> Contractor's Name ......... ..............................License Phone ... <br /> Installation will serve; Residence Vf Aoartment House 0 Commercial.:E]Trctiler Court 0 <br /> Motel [].Other -------------- ------------------ ......... <br /> Number of living units-../.--. Number of becrooms ..Garbage Grind;r ,Lot Size 1?-111__;-__'X 4-.----------- <br /> Water Supply, Public System and name ...C�&-kr --_------------------------- -------•......Private <br /> Character of soil I to a depth of 3 feet.- Sarvd'Ef, Silt 0 -Clay 0 Peat[J 'Sandy Loom 0 Clay Loom <br /> Hardpan E] Adobe;9 Fill Material ............ If yes,type ............................ <br /> Plot plan, showing size of-lot;-location-of system in relation--to wails;-buildings,-etc. must be placed Ton,reverse side.) <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200I,feet,) <br /> PACKAGE TREATMENT SEPTIC TANK,[ Size............ .................................... Liquid Depth ................ ... <br /> Capacity .................... Type ..................... Material-----.`.._._..._..._... No. Compartments ........ .......... <br /> Distance to nearest: Well ....................................Foundation Prop.,,Line ...........­­...... <br /> LEACHING LINE No. of Lines _...________________I--. Length of each line---------- Total, Length. .9.._.......__............. <br /> ._ _..._..Depth MoteridlD' Box er _�i............ ..... .... ......... <br /> ...... ................. <br /> Distance to nearest: Well .......... Foundation ...... ---- Property ,�Line <br /> 4. <br /> ';;SEEPAGE PIT Depth .................... DidrnVter ......t ...... Number -------------------- .......Rock Filled 1Y6',-st'❑ No <br /> Water Table Depth ------ ....................................Rock Size ............. ............. <br /> Distanceto-nearest:.Well-t."-.z. ........... ..................Foundation .......... Prop. Line ...................... <br /> .-� ", <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ....... <br /> .................. -------------- Date _......... ...................... <br /> Septic Tank (Specify Requirements)`• ......... ... ........ ............ ........ ;�._...._._................. <br /> . ................. <br /> Disposal Field (Specify Requirements) ...... <br /> A -------------------- <br /> 0, ................. .........I............................. ----- --­---------- ......... <br /> . ............. <br /> .............I.................. ------------------------------------:�!tv---------- -------------------------------------------------------------n............ ---------I............................. <br /> (Draw existing and required cidditfon on reverse side) <br /> "A) <br /> I hereby certify that I have prepared this application-and thatithe,­,;Arork will b'e done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules acid Regulations'ofxthe'.Scih,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." rT <br /> Signed Owner <br /> ------------------- -- ................ ......... .. <br /> T <br /> By ................ ....... ------------------- <br /> !tie e* <br /> 0------------Z------ .... <br /> (If er than owner) <br /> FOR DEPARTMENT,USE ONLY <br /> DATE�_ <br /> -Y..... <br /> ------------------------ <br /> APPLICATION ACCEPTED BY .........opoo. ------I........ ... DATE -... <br /> ......................&­............DATE ....... ................................... <br /> BUILDING PERMIT ISSUED ------------- ------ .......................... <br /> ADDITIONALCOMMENTS ...........4 ....... ........................................... ................................................ <br /> ..................................... .................................................... <br /> ............... <br /> ............. <br /> ........................ ----­------------- ..........................­....... <br /> ..... ..................... ... <br /> ..........I.............................................W. <br /> .... ................... . . .. ............ •.._.._._.:................_-•...-----...---.._._.... <br /> ...................... ............ - ----- --- --- _- <br /> FinalInspection by. .......... ................ ......................­..................... .......Date .. ... . <br /> ....... -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r w 13 24 I.-AS; Pau _J;AA 7/72 3 <br />