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FOR OFFICE USE: <br /> ...........­.................. .......... APPLICATION FOR SANITATION PERMIT 176 <br /> (Complete In Trilicate) Permit No. ............ ........ <br /> ...._.._._..I...._....... <br />► <br /> Date Issued <br /> ........................... ..................... This Permit ExPAW—iff"Year From Data 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 mod(i In compliance with County Ordinance No. 549 and existing Rules and Regulations.. <br /> I <br /> JOB ADDRESSAOCATION i.......GcSZ_10. <br /> 04.1,d_ .........•------ ....................CENSUS TRACT ........ ...... <br /> Owner's Name ...../4"tia... I..... . ...............---------­----r--------- ............ .........Phone ... ....... <br /> Address ....----- _--oi-ko <br /> .. ....... <br /> ••-•---•----•-----. ................ city .............. ................... ....... <br /> Contractor's Name ......._A(4a.cj�------_---------- ................................----....License # ---- ................... Phone .......... ................... <br /> Installation will serve: Residence OR/Apartment House C] Commercial :[]Trailer Court 0 <br /> Motel [] Other ............................................ <br /> Number of living units:..._.r__.... Number of bedrooms ..4------Garbage Grinder ............ Lot Size .... <br /> Water Supply, Public System and name -------------.......• .....----------­-------....................................................Private <br /> Character of soil to a depth of 3 feet: Sand El Silt[] -Clay [I Pe't F <br /> a Sandy Loom C] Clay Loom ❑ <br /> Hardpan ED Adobe (Fill M6teriat ............ If yes,type ............................ <br /> o <br /> (Plot plan, showing size of 16t, 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 /> PAC KAGE`TREAT_MEN_ _ __ <br /> f_[ _ftt_VTid fAAN k <br /> I Size,.*............. ................................... Liquid Depth ................ <br /> Capacity ... 7TYpe .... . . Material...................... ..NO. -Com pa rfm—ekt .......... <br /> ............... ... . s <br /> Distance -tc;Lnearest: Well ................. .::...............Foundation ....................... Prop. Ll'nie ..................... <br /> LEACHING LINE :No. 'of Lines ................__-7—tength—of each ..........7.-t—_T6ftaI-1indth <br /> ............ <br /> 'D' Box _............ Type Filter Material ....................Depth Filter Material .... ................. ........... ..... <br /> Distance to 'nearest. Well ........................ Foundation .... ......;------------ Property'Llne ........................ <br /> SEEPAGE PIT, )I Depth -,........ .......... Diameter ........... .... Number ------------------- ........ Rock Filled Yes ❑ No ❑ <br /> Water-Table Depth ................................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ....................... <br /> REPAIR/ADDITION(Preva Sonitdtio,'n-'Permit# -------------------------------------------- Date .......... <br /> •..................... ............................. <br /> Septic Tank (Specify Requirements) ............................................................................. <br /> Disposal Field (Specify. Requirements) .....l(k.1-d ....... 12 <br /> ............ <br /> ..............7'V <br /> ------_---- --------------------- ...... ------------------------------------ <br /> .......................... ----------------------------------------------------------------------------------------------- ........................... ......__...................................... <br /> Draw existing and required addition on reverse side) <br /> I hereby certify that I°have';.prepared this application and tkat,the,.work will -be.done -in-,acci;r'd once With 'San� Joaquin <br /> County Ordinances, State-Laws, and Rules 'and Requicililons of the Son Joaquin' Local JHealth biitrici. Home owner or licen- <br /> sed signature certifies the following-: <br /> "I certify that in the performs ce of the work for which this permit is issued, I shall "not employ -any..person in such manner <br /> as to become su *ec or4an's.Cpm' California."e Compensation laws of Californ <br /> Signed ---_....... - - -­ Ve t. 't, <br /> 0 <br /> . .................................... ........ Owner <br /> By .......... ............... <br /> .. ...... ......................... <br /> ------------------------------------ ..... .Tiiie ................................. <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY... ....... -------- - 0 <br /> . ...... ............................ DATE ........... ..... <br /> BUILDING PERMIT ISSUED .......................... I...................... . .................................. ........DATE ....................... ................... <br /> ADDITIONAL COMMENTS ... <br /> .......... ... <br /> ...................................................... ... ......-...... ------- ..... ------7-........................... ---------------- ................. <br /> - --- ----------------­ ..................... ............. <br /> ......................... . . ...... <br /> Final Inspection by: ..... .. ....... .... ............ .... . <br /> -- ---------- ............... Date ... <br /> CAL <br /> ...---- <br /> SAN JO QUIN 0 HEALTH DISTRICT <br /> :L.,L- - *1W <br /> E. H. 13 24 1-'68 Rev: 5M 7 71 'A M <br />