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I <br /> FOR OFFICE USE: APPLICATION FOR,.-SAITATION PERMIT <br /> Permit No. <br /> -------------------------------- ----------------- <br /> ______ <br /> - <br /> (Complete in Triplicate} , <br /> This Permit Expires 1 Year From Date Date Issued <br /> --------------------------------------------------------- <br /> I <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 opplication_is_nade in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> I CENSUS TRACT l2?-o <br /> JOB ADDRESS/LOCATION / _1�- ---- - ----- - ---- -- - -------Phone ------------ ----- ---r--o- <br /> 02� <br /> s Name ---- ---- - - -------------- ----- <br /> Owner' <br /> --" cityz, `Address ...VAl AelA1 - --------------------------------------------------------- nse # Phone ------------- <br /> -----------•----- <br /> Contractor's Name f _7; --------------- --Lice <br /> Installation will serve: Residence [] Apartment House❑ Commercial ❑Trailer Cot rt ;[IMotel [-] Other _ � ----------------- <br /> Number of living units_____________ Number of bedrooms ------------Garba_ge Grinder ------------ LoltSize � - -� +'------- <br /> Water Supply: Public System and name ----------------- ---•--------•------------- ------------------------•----------I-----------------------------Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay E] Peafi,� Sandy Loam ❑ Clay Loam F] <br /> IM __f� <br /> Hardpan ❑ Adobe-❑ Fill Material ------------ If yes,type ----------------- ---------- <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,) <br /> PACKAGE TREATMENT f I SEPTIC TANK f ] Size-------------------------------------------1----- Liquid Depth --------------------,----- <br /> capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------•------------- <br /> C �/ <br /> Distance to nearest: Well ____________________________________Foundation _._.-I1--------------- Prop. Line --------------1- <br /> LEACHING LINE " [ ) No. of Lines ______________ ______ Length of each line-------___________..-___��__ Total Length OS_X__ j0-------- <br /> f, II <br /> D' Box __ Type Filter Material Depth Filter Material _____ _�rf__"_____.______________________ <br /> Distance to nearest: Well _-/0_D_r_______- Foundation ----l0---___ ___-_ Property Line ____�elT-__-__-___ <br /> SEEPAGE PIT f Depth ___ Diameter _______________ Number ______________________ _____ Rock Filled Yes ❑ No (3Water Table Depth ------------------------------------------------Rock Size ---------I�------------- -------- <br /> Distance to nearest: Well ----------------------------------......Foundation ------1( Prop. Line .._________-___--._-.- <br /> REPAIR/ADDITION(Prev. Sanitation Permit r# -------------------------------------------- Date ------------------ ---------------) <br /> --------------------------- <br /> Septic Tank (Specify Requirements) -------------------------------------- ------------------------------------ •----------- <br /> -Disp sal Field (Specify Requirements) ---s// �- -- --------•--------------- <br /> -- -------- - --- ------- - - - <br /> ' --------------------- <br /> ------ --- - - -- - -- <br /> (Draw existing and quired addition o everse side) <br /> -1-hereby certify that 1 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: M <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 s to Workmar}s Compensation laws of California." <br /> Signed -------- -- - -- ------------- --- Owner <br /> ' Title ----------- -- ------------ <br /> Sy -----------.---------- ------------- ---- --- --- f <br /> [If other than o ned <br /> FOR DEPART,IIENT USE ONLY <br /> APPLICATION ACCEPTED BY -- �N DATE <br /> BUILDING PERMIT ISSUED ----- --------------------- --------------------------- ---- - <br /> -------------------=---------11-- DATE ------------------------------------------- <br /> ----------- <br /> IADDITIONAL COMMENTS ----------------- -------/---------------------------------•-----------------------------------------"1------------------ --------- --------•------------------ <br /> -------------------------------------- -- ----------- -- --------------------------------------------------------------------- � <br /> 1M <br /> ------------------------------ -------------- - -- ------ - - -------------------------- <br /> M ------- -------- --------------------------------- <br /> ----------------------------------------- n z — -- -------------------------------------------------------------------------- 0----------------- -- -------------------------- -------- <br /> i �M._ Date - - � _ ------------ <br /> Final Inspection by: ------ -C <br /> i 5 JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />