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FOR'-OFFICE USE: <br /> AP ..-._--ION FOR SANITATaON, PERMIT rr — p <br /> ------------------------------------------------------- <br /> Permit No. 4-9-7-5.77P <br /> (Complete in Triplicate) <br /> ----------------------------------------------------- <br /> Date Issued ------------------- <br /> Application <br /> _��l�~ <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 /> y � CENSUS TRACT --------- -- <br /> -------------- <br /> JOB A'DDRESS/LO�CATIO _ _:Pr,,F------------- <br /> ---------------------Phone <br /> ---- ---------------------Phone -W-A y/------ ------ <br /> t <br /> Owners Name City s " --------- - --------------------------------------------- <br /> Address r <br /> Contractor's Name -_411192?t- ----------License # ------------------------ Phone ------------------- ---------- <br /> Installation will serve: Residence [�]Apartment House❑ Commercial ❑Trailer Court ;❑ I <br /> Motel ❑ Other -------------------------------------------- <br /> Number <br /> ------------------------------------------Number of living units:----------- Number of bedrooms _q--------Garbage Grinder _.______..- Lot Size <br /> Water Supply: Public System and name ------------------------------ Private IK] <br /> Character of soil to a depth of 3 feet: Sand[] Silt❑ Clay ❑ Peat ❑ Sandy Loam '® Clay Loam F] <br /> Hardpan ❑ Adobe 'El Fill Material ------------ 1f yes, type ---------------------------- ,s <br /> (Plot plan, showing size of lot, 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,) N' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK W Size--y-t__H----'r-r---------------------- Liquid Depth ----------------------.---- N' <br /> PACKAGE <br /> Capacity/6170------. Type 4 ----e Material__ ---------- No. Compartments ------------ ---• �I <br /> Distance to nearest: Well ---Ire-------------------------Foundation ___- --------- _- Prop. Line _Y0--------------- <br /> LEACHING LINE [ No. of Lines _Y-------------------- Length of each line__-�!,P-_---------.-.---- Total Length P�----------------- <br /> 'D' Box ------ ---- Type Filter Material _�°A----------Depth Filter MaterialAX'-------------------------------.___. <br /> Distance to nearest: Well _70---------------- Foundation _'_ ________________ Property Line 1_--_-____--_--.----- <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- 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 ----------------------------------) <br /> Septic Tank (Specify Requirements) -------------------------------------------------------------------------------------•-------------------------<---- ---------------------- <br /> Disposal Field (Specify Requirements) <br /> -------------------------------------------------------------- <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 /> F County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne 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 becomeeuubject to Workman's Compensation laws of California." <br /> Signed 77 �_ - '------------------- .nem <br /> ------------ofitle ------ ---------- ---------------------:---------- ----------------- <br /> By <br /> (If other than owner) <br /> FOR DEPA-At ENT USE ONLY <br /> APPLICATION ACCEPTED BY ../ __. ------ -------------------------------------------------------- DATE <br /> BUILDING PERMIT ISSUED -------------------------------------------------------------------------- <br /> --------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -------------- ----- ------------ ---------------------- -------------W", <br /> ------- <br /> --------------------------------- <br /> --- <br /> ------------------ ----------------- - ----------•- ----------------------------------------------------------------------- <br /> ---------------- ------------- ----- ----------- --- <br /> - - r - <br /> Date -f--- ---- --------- -- ---- <br /> - - -- --- - - - <br /> Final Inspection by: --- -- ---- - ------------------------------------ - -------------------------- <br /> SAN JOAQUIN, LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />