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FOR OFFICE USE: <br /> rr APPLICN ION 'ICOR SAN' ITATION PERMIT <br /> -'---'.—"— yrs.- .-� <br /> ..�_----- , . r ^.� _ _. _. r Permit <br /> = -------------�Q. <br /> Tomp efe in,l"r`ipll"c�a �...._„-...�...�,..�Y,...-• - - - .. <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin uin Local Health.District for a <br /> PP Y q 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 _.-` -6_-w= _d-c CENSUS TRACT <br /> Owner's Name .- ] ur -----------------------------k----------------- -----------------------Phone <br /> Address ------ ------------------ -----. City <br /> Contractor's Name - _ c;r - � }___.License # GS=. y Phone <br /> Installation will serve: Residence Apartment House,J] Commercial ❑Trailer Court ;❑ <br /> I <br /> I Motel ❑Other - <br /> _Number of living units:---_f----- Number of bedrooms ___3------- Grinder .- Lot SizeC—__----------------- <br /> Water Supply: Public System and name ---------------------------------------------------------------------------­---------------------------- Private <br /> Character of soil to a depth of 3 feet: Sand'E-] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> . I <br /> --~—~---Hardpan ❑ Adobe V Fill Matbrial ------------ If yes, type -----------------------___- Z <br /> (Plot plan, showing size of lot,flocation of system in relation to wells, buildings, etc. must be placed on revere side.) 1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> U � <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------ _ Liquid Depth ---------.------_----.-__- } i <br /> Capacity ---/vlo.d----- Type Material)--��-,,rr No. Compartments ---- -------:---- <br /> �f <br /> s Distance to/nearest: Well --------il1 _________________Foundation -.--.--_-fid------ Prop. Line ._- ___-_.-_ <br /> LEACHING LINE [ ) No. of Lines € '�---------.__ Length of each -------- Total Length .---- ----=-------- 1 � <br /> 'D' Box -777- Type Filter Material ---1-.Y ------Depth Filter Material -------' _------------------------- <br /> jDistance to nearest..-Wel -:-_Foundation --------/ .---__.___ Property Line -.�"__---= <br /> SPAGE PIT [ ] Depth ----�.--- .-_____ Diameter _Y/d__ Number _.----.-.._4--•-__________ Rock Filled Yes �' No <br /> EE <br /> € Water Table Depth .'--------IF--_ Size. _ _ <br /> - ------------------•--------Rock .- -'-��----------•--••---- <br /> -----/0---------- Prop. Line i;5_:_: <br /> I <br /> Distance to nearest: Well ----/6�--------------------------Foundation ____..-_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------- -- <br /> --------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements)..--------------------------------------------------------------------------------C- <br /> Disposal Field (Specify Requirements) ------ ------------------------•------------------------------------------------------------------------- ------ <br /> t- <br /> ------------------------------------------------------------ - ---- <br /> ------------------------- <br /> --------------------- ------------------- ---------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required 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 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 subject to Workman's Compensation laws of California.” <br /> Signed ------------------------- <br /> -- -------------------- -------------------------------- Owner <br /> jTitle <br /> ------------------------- ---------------------------- ------------ ------------------------------------------- <br /> B y <br /> (If <br /> other tho wned I <br /> ARTMENT USE ONLY ; <br /> APPLICATION ACCEPTED 8Y -A -- - -------- - ------------------------------------------------------- DATE .... -------- <br /> BUILDING PERMIT ISSUED --- -- -------------------------------------------•----- --------DATE <br /> ADDIrTIONAL COMMENTS ------ ---- __ <br /> -- ------------------------------------------------------------------------------------------------•---- s- <br /> -------- <br /> --------------- <br /> ; <br /> '---------------------------- ------- --- - ----- -- -------------------------------------- ----------------------------------------------------------------------------------------- <br /> --------------------------------------- <br /> Final <br /> Final,Inspection by: - -- - - - - - -- <br /> ------------------------ -Date ----' �3� <br /> AN_,)OAQUIN,LOCAL HEALTH_.DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />