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FOR OFFICE USE: <br /> APPLICATION FOCSANITATION PERMIT .. <br /> —� <br /> w .. <br /> -. _,�st M, �. � _ Permit No. --•-- <br /> ., «�- 6 4 ICo p11' , Triplicinte} .r ._- _ <br /> Y y 4 <br /> . Date Issued __. '�S_ <br /> ` 4 This Devi ntt Expires ...- from Date issued <br /> Application;is hereby made to the San Joaquin Local Health.District fora permit to construct and isi'still'tiie work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules` and Regulations: <br /> JOB ADDRESS/LOCATIONL} - CENSUS TRACT `_,.� <br /> Owner's Name "------------------------- ----------------------- ---Phone -c l <br /> Address --J57Y)K--\-Lis-------- -------- - - r �---------- ----- CityJ [_L,c------------------------------•-••-- <br /> 14_ f_7 <br /> Contractor's Name ____ _ --------- .____.__ -------- Phone <br /> ------- <br /> ----License # <br /> Installation will serve: Residence;N'Apartment House❑ Commercial❑Trailer Court i❑ <br /> tel <br /> Other - <br /> Number of living units:___/ _ Numberofbbeedrooms; l <br /> g r- - bedrooms'---3 Grinder ------__ -- Lot Size ------I/ <br /> Supply: Public System and name ---------------------- ------ •-• -- - *--------.Private ( ' <br /> - - ---_�--------- ---------- ----------.-- <br /> Character of soil to a depth of 3 feet: Sand I-] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑,- Clay Loamx <br /> t <br /> 1 Hardpan E] Adobe E] Fill Material _____.______ 1f yes,type ____ ________________ __ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. mustbe plated on reverse side.) <br /> NEW INSTALLATION: (No septic tank o„seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK'[.] Size----------------------- ------ -----; Liquid Depth -------------------------- <br /> Capacity __I�ld--____Type/P� - Material -wc la_ No. Compartments __z.............. <br /> Distance to nearest: Well -----/-'d____________________Foundation _____/i?__________ Prop. Line ___.. ----_____---__ <br /> LEACHING LINE C ] No. of Lines ----3----------- Length of each line----A1P-------------- Total Length ___:3.i_.e)_____-_.-_-__ <br /> 'D' Box 'LJ 9-_ Type Filter'Material ----- _ ------Depth Filter Material If---------------- --- <br /> Distance to nearest: Well ------jle------- Foundation --------/_o----------Property Line _=_............. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter V,------------ Number ------------------------ --- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ---------------------------------------------- Rock Size -------------------- ----------- <br /> Distance to nearest: Well ----------______\_�----------._:--:-Foundation -------------------- Prop. Line ____ ....______..__._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------- ------------ Date -------.--------•-----------------I k <br /> Septic Tank (Specify Requirements) -------------------------- ------------------ ----------------------------------- <br /> DisposalField (Specify Requirements) ----------------------------------------------------- -------------------------------------------------------------- ---------------- <br /> ' ----------------------------------------------------------------------------------------------------- --------=---- ---------------------------- ---•---------------- <br /> ------------- - -------------------------------------------------- ----------- --------------------- `------------------------------------------------------------- ------------ --------- <br /> i (Draw existing <br /> and re--uired addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son 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.” \!,{ <br /> Signeedd - - --- *(ifother <br /> - ----- -- ---------------- -------------------------------------- Owner <br /> BY -X ---------------------------------------------------- Title ------------------------- ----------------------�-�-------------- <br /> than ow er) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - -- - -- ---------'�"-,-----------------------------------------------------------------. DATE _ " --------- <br /> BUILDINGPERMIT ISSUED ---------------------------------- ---------------------------------------------- -----------------------DATE ---------- ---- ---------------- =- ------ <br /> ADDITIONALCOMMENTS ------------ - ------------------------------------- -•------------------ -------------------------------------- ---------------------------------------- <br /> I <br /> -------------------------s----:-------- <br /> `-------------------------------------------------------------------------------------------------------------------- ------------------------------ -------- ------------------------------------ <br /> ------------------------------------------------------------------------- -------------------- --------------------------------------------------------------------------------------------------- <br /> ' n ------------------------------------------------- ------ <br /> ---- --------- <br /> ---------------------- <br /> Final , <br /> Ins ection ----------------------- --------------------------------------Date ---- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ ­e <br /> E. H. 9 1-'6$ Rev. 5M <br />