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FOR OFFICE USE: 1 <br /> APPLICATIONFDR SANITATION PERMIT permit No. _-Z�'_=�`�3-_ ` <br /> (Complete in Triplicate)' �'0---------- <br /> Date Issued <br /> ---------------------------------------------------------- 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 ma ompliance with County Ordinance No. 549 and'existing Rules and Regulations. <br /> y �—�"—'�` -CENSUS-TRACT'-'-" __�"-____-____ <br /> �_' <br /> JOB-ADDRESS/LOCATION- ---- ---- -- 1---%cox: <br /> fico- � ,- ----��-- � <br /> Owner's Name -------------------- = Phone <br /> ` <br /> _ _ <br /> ( Cit { '- <br /> Contractor's Name __.__ ------------------------------- -- License # _ (od_ rJ _ __ Phone J__rU ___-. <br /> Installation will serve: Residence Pr Apartment House,0 Commercial ❑Trailer Court l❑ <br /> 1 Motel ❑Other -------------------------------------------- <br /> Number <br /> --------------------------------------- --Number of living units::---I_.____- Number of bedrooms _N_.e1-.Garbage Grinder --__` ___ Lot Size ----------------------------- <br /> Water Supply: Public System and name J- ------------------------------------------ --------------------------------------------- Private El <br /> Character of soil to a depth of 3 feet: Sand❑ Silt E] Clay ❑ Peat❑ Sandy Loamy Clay Loam <br /> 1 Hardpan Adobe ❑ Fill'Materia) ------ If yes, type --------_------------------ <br /> (Plotiplan, showing-)size of'lot, location of system in relation to wells, buildings, etc.. must be placed on reverse side.) <br /> NEW INSTALLATION:f (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT r( ] SEPTIC TANK'( = t Size------ ------- Liquid Depth -__ of_---_______- N <br /> f P Y I � -= Material ____ No. Compartments __..-.- <br /> f i 4 <br /> Distance e t�(1� � - Type ----- - ----- ---- - � i <br /> ' nearest: Well ____---- _�1_CJ_ �:___--.-Foundation ____�y <br /> + l � _� a'`-. - - -- _ Prop. Line s:�e-�:------ <br /> LEACHING LINE rNo. of Lines 1--------�------------ Length of each line-------�J�____..______ Total Length ___/-_7C._._.......-_ <br /> : D' Box .__l__.____ Type Filter Material _____________Depth Filter Material ---------1_1.57---------------------- <br /> Distance <br /> ____________ ___ _Distance to nearest: Wel!•,__,,ld r� ._~,__.,Foundation _.-__ -=`-<_ Property Line ___&'....... ........ <br /> SEEPAGE PIT [j(i Depth ----- Diameter _ _ Number ------- __ - -----. Rock Filled Yes No <br /> l - `" iy Cl <br /> Water Table'Depth - I cl --,-------------------Rock Size --------- ----------.----- <br /> T >i/IJCJ <br /> Distancef to nearest:Well ----____-_____________________________Foundation Q Prop. Line ... l.J-___. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --.----.----�------------------------------- Date --------------------------•-------) <br /> Septic Tank (Specify Requirements) -------- _ -e ----------------- -------------------- - <br /> Disposal Field (Specify Requirements) _ �`'------ - - - <br /> r <br /> -------------------------------------- - ---- <br /> - ----= .. = = -= ---- <br /> ----------------------- <br /> 1 <br /> --------------- ------- ---------------------------------------- ---------------------------------------------- ------------------------------------ ------------- <br /> (Draw existing and required addition on reverse side)) - <br /> I hereby certify that I have prepared this application and that the work w4111 be done inaccordance with Sart Joaquin <br /> County Ordinances, State Laws, and Mules and Regulations of the. San Joaquin Local Health District. Home owner or licene <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 /> Y ---r ------ -------------- -------- ----- Owner <br /> Signe Title ------ ------------ <br /> B --------- <br /> (If other than owner) <br /> :;Z&,��follv*PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ------ --- -- -- - ---------- ----------------------------------------------------- DATE <br /> BUILDING-PERMIT ,.ISSU.ED------ �� -- - ------- - =----------- ---------------- DATE.---.tea= --------------------- <br /> ------------ <br /> ADDITIONAL COMMENTS ---- ----- 11-------------'----- - ------- -- --------- - ------------- <br /> t <br /> --- ------------ --& - ---- j � cam, g� �CPrl . a {�` <br /> __________ __________ -----------------------------_________________-_._____________-____________.____._ ________________________.---------------------------------------- <br /> _e <br /> _________________________________________ ______ ------ <br /> _ _ ----------------------------------------- <br /> ______-_-- ________________-_---_____________.________-_-__-____-______ _____________ _-_- <br /> Final Inspection by; ------ ------- -- - ---------------------------------------------------------------------------.Date _. `/ �� <br /> gaJOAQUIN ----- -- <br /> LOCAL HEALTH DISTRICT <br /> F. H. 9 1-'68 Rev. SM <br />