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f . FOR OFFICE USE: <br /> X3 - . APPLICATION, I:<OR'SANITATION PERMIT <br /> 1 52.2 ----------------------- ` r ----- (Complete in Triplicate) Permit No: . - o-� <br /> - ------------------------------------------i{ S <br /> Date Issued ___7--9=.7v <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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION . f �a6_lro)/_ed✓_::p---------------------------------------°---------------CENSUS TRACT 16------------------ <br /> 4;Name --- �- -C � ---- 1-f< ----------------------Phone •-- r <br /> Address �.7 1& .T= ` ---------------•------- ---------------------------- ------------ City -� fe*!'� -"-- -----------------------------------•--------------- <br /> Contractor's Name -._ e �� rte/---------------------- --------License #1110- ---- Phonex"_-r2��1 - <br /> Installation will serve: Residence 4 Apartment House-[:] Commercial ❑Trailer Court <br /> Motel ❑ Other -------------------------------------------- - <br /> �► . ___ Q i ` <br /> Number:of Eiving units:_.__.____-_ Number of bedrooms _ ______Garbage Grinder �._-___ Lot Size -------- <br /> Water Sb.pply: Public System and name ------ -----------------------=---------------------=------------------------------------------------ Private,K <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> t� <br /> Hardpan ❑ Adobe;[ ] Fill Material ------------ If yes, type ---:--_-------------------- <br /> (Plot <br /> -------------- --(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I <br /> p„ <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200..feet,) Y <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size------------------------------------------------ Liquid Depth ------------------------.- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------------- ----•--- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------__------- <br /> s <br /> LEACHING LINE [ I No. of Lines ________________________ Length of each line---------------------.------ Total Length __--_____--.______..;.._.-_ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------'-`.• <br /> Distance oto nearest: Well ------------------------ Foundation - ---------------------- Property Line ------------------------ <br /> SEEPAGE <br /> _____-__--___ ------SEEPAGE PIT [ ] Depth _____________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No P❑ <br /> Water Table,.Depth ------------------------------------------------Rock Size --- ---------------------------- <br /> Distance to nearest: Well ----------------------___-_-----------.Foundation -------------------- Prop. Line -------- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit �. --'------Date,# -------_.-�------ -- ------ ------- -- ___________________._________-_-_-1 <br /> Septic Tank (Specify Requirements) --------'-------------- f ----- ---------- -----_-- ---------------- ---�r--------- <br /> ---- ---- <br /> - <br /> Disposal <br /> � <br /> Disposal .Field (Specify Requirements) _�I- t -d�``-fir' . W- ) --- i- ------- ~--�?--3- -z-'��-- <br /> ----------• -AZ Awl , '' t = ; <br /> N <br /> _ ----------------- <br /> ,. (Draw Existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this applicationaand that the wdrk 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:41 _­ ­_ ` —_r <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 --- ----------?othan <br /> ------------- - ---- -----------------------__-_':---------- Owner <br /> __ Title <br /> (lowner) <br /> EPARTAENT,USE ONLY <br /> --------------- <br /> APPLICATIOP ACCEPTED BY -------------- <br /> ------ -------------------------------------------------------- DATE <br /> i BUILDING .,_ERMIT'-ISSUED _-' •_"„ .. -.-:. DATE --------- �`---' <br /> I ADDITIONA C MMENTS _ ._ --- -- --- --_--- ---` -- ---------=���`'-'� _Ot.I_,0.- :.�X rTca �'p <br /> ----- -----�-- - -------------------- ------------ ---------- - ------------------------ <br /> -------------1 l.�r- ----- __-------- ' -- ----------- -=-------------------------------=--------------- ----------------------------------------------- ---- <br /> ------------ -------------------- - ----- --------------------------------- ---------�------------------------------------------ ------------------- ---- ------------------------- <br /> Final Inspection by: -------------------------------------- '----------------------------------------.--Date ---/2--79' 24-------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6 Rev. 5M <br />