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FOR OFFICE USE: APPLICATION FOS SANITATION PERMIT <br /> ---------------- ------------- Permit No: ------ 3 03 <br /> (Complete in Triplicate) <br /> ---------=----------------------------------------------- <br /> \,� Date Issued -- -»'-� . <br /> _________________________________________________________ vc This Permit Expires 1 Year From Date 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO C1� l� r� � -`'�� �'---a-------- ------CENSUS TRACT ---------------- •-------- <br /> Owner's Named L /amu -C �l ------------------Phone ------------------------------------ <br /> ----_------.- <br /> Address ---------- 1_6- ----- ------------- City ------------------•-------------------•------ <br /> Contractor's Name ---------- @/ ---------------------------------------------------------License # ------------------------ Phone <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -----------------------------------•-------- <br /> Number of living units:----I------ Number of bedrooms _--2------Garbage Grinder ------------ Lot Size -_-________.________________________•--_- <br /> Water Supply: Public System and name ---------------- - - ------.Private <br /> Character of soil to a depth of 3 feet: Sand'�It❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;F� <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________________-_-_--_ <br /> (Pl'ot 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 permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'r / Size----------------------------------- Liquid Depth _____-______..._._._____. <br /> Capacity _/__-�D0------ TypePrA<4?�, ____ Material•__ cf' No. Compartments ____-- <br /> Distance to nearest: Well --- r>?`_---------------------Foundation --------- Prop. Line ___�..._._._.___ 0 <br /> LEACHING LINE [N' No. of Lines _____ __ -__ Length of each line______ g 1 <br /> �- ------- ��----- ------ Total Length ----,164-------------- ^� <br /> 'D' Box e& ?4______ Type Filter Material/_`_-____--_-Depth Filter Material _-__---- - �1 <br /> Distance to nearest: Well _- _��_____f_ Foundation _/_ _� ___- _____ Property Line ___ _.../--.._..__ <br /> niT j XX <br /> ,�,,.��,-,r- [► Depth -- --------------- _____-____ Number --------� ________ ______ Rock Filled Yes ®�No i� <br /> Water Table Depth ------------------------------------------------Rock Size -------------------•------------ 7 <br /> Distance to nearest: Well _-______-____________________________Foundation -------------------- Prop. Line ...................... <br /> 7 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date _______-________•---___-_______--.) <br /> Septic Tank (Specify Requirements) ------------------- -----------------------------•---------------------•---•----------------•---- -----------------------------• 1 <br /> Disposal Field (Specify Requirements) ________________________ -- ------ <br /> -------------------- •--------------------------------•--------------•----------------- <br /> - -------- ---- -- --- - - - ------------- ------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaqui <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 subteA to Workman's Compen tion laws of lifornia." <br /> Signed ----- --- ---- --------- � `" Owner <br /> BY ------ ------------------- - -- ---------------- ---------------------------- Title - <br /> (If other than owner) <br /> lei FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- Z4, - -------------------------------------------------- DATE -----7 -//-s----\3---------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE -------------____________________ <br /> ADDITIONALCOMMENTS -------------------------------------------------------------- --------------------------------------------------------------------=-------------- - --------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•----- <br /> ------------------------------ <br /> -------------------------------------------------- <br /> -----------------------------------------------------------------------------------------------------------.--------------------- <br /> - <br /> --------------- <br /> - ------------------------------------------------ ` - - - - - - - - - - - - - - <br /> � �Final Inspection by: ------------------------------ _-•--------- Date ----7 -= -- 1 �------•-•----- <br /> ,; <br /> SAN JOAQUIN LOCAL HEAl` . DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />