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K urnc:r use: ApPL.CATION FOR SANT` `4N PERMIT <br /> .. -- -•----- ------------------- <br /> I .� Permit No. _%6_-�a _ <br /> �- ,i;� (Complete in Triplicate) <br /> 1, This Permit Expires 1 Year From pate Issued <br /> °L Me Issued <br /> ..�........... <br /> .......................... P <br /> -1 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 latiop <br /> FJOB ADDRESS/LOCATION ......__ _ 4.11 f_C ..-----. IZ _ G��-_.. _1-5 Ll�S' /ILCEN U5 TRACT ----------------- ....... <br /> _..........Phone . <br /> -. <br /> Owner's Name - ��.----- � ��14­ <br /> - -------'Ci �---•................ _ .. _..-• -�-•----�-- 1, <br /> a <br /> Address .._..� _ S�_._ �U` . .� 1 _` ��` .�: , ty ._..._..(� -- <br /> Contractor's Name -----SJ41-------- -------------------------- License # -----------•---•-•------ Phone ..._ ------•---------------- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial❑Traller Court <br /> Motel ❑Other...... -•--------- ......................... <br /> Number of living units------------- Number of bedrooms ............Garbage Grinder -_..__..-- Lot Size ----------------------- -------------------- <br /> Water Supply: Public System and name ------------------•---•-----••--------------•------------------------------- ------------------------------Private ❑ <br /> Character of soil to a depth of 3.feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑. Clay Loam ❑ <br /> Hardpan 0 Adobe❑ fill Material -.__.... ... If yes,type--------------- ---------•-- <br /> (Plot plan, showing size of lot, location of system in relation to wefts, buildings, etc. must be placed on reverse side-) <br /> NEW INSTALLATION- (No septic tonic or seepage pit permitted if public sewer is available within 240 feet,) <br /> . PACKAGE TREATMENT { ] SEPTIC TANK f)j� hi,(/ --93k ---------------------------------C % ........... Liquid. Depth ....--..------------------- <br /> -5/ . <br /> Capacity --------------•------ Tyle .......•............ Material.............. --•---- No. Compartments ----------------------1C <br /> Distance to nearest: Well --------------•-.--•-•-------..._...Foun tion .__.......__ ......... Prop. Line --- ---- <br /> LEACHING LINE {fJ No. of Lines -------------- Length of each line..---_---- 'Materia <br /> Total Length :__ ............... <br /> . <br /> I/- D' Box .__./----- Type Pilfer Materia! .�.De th .Filter Materia! ._"!. //19 --•-•-_-_-_•______-. <br /> i <br /> Distance to nearest: Well -._-F----_-1�...... Foundation Property Line ... ................. <br /> SEEPAGE PIT { ) Depth -------------------- Diameter ----------- ---- Number ......_._._._.-....---..... Rock Filled Yes ❑ No ❑ . <br /> IWater Table Depth ---------................... --------------------Rock Size ------------------•------------- <br /> Distance to nearest: Well ............................:...........Foundation -------------- Prop. Line .._._----------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit;# -------------------------------------------- Date -_---------------------------------1 <br /> I j Septic Tank (Specify Requirements).---.-----------........................ -------•------------------•-----•-•-- --------- -----._---•------•---•-----••. <br /> t Disposal Field (Specify Requirements) ----------•--- ---- ----------- -------------- ------------- <br /> ------------------------- ----------------------------------------------------- . ................. .._.. .__.....-----......---....-- _...._ -------------- -------•-•-----•-•------ <br /> M a <br /> I- ----------------------------------- <br /> ........................................ <br /> fDrow existing and required addition on reverse side) <br /> 1 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 Heatth.DIstrict. Home owner or lken- <br /> sed.agents signature certifies the fallowing: - <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 /> Ffas b orne subject to Workman's Compensation laws of California." <br /> 3(Signe - Owner <br /> By -------------- ------/----------- � --------- --- Title ............... --- <br /> (If other than owner) <br /> FA DEPARTMEXT USE ONLY <br /> APPLICATION ACCEPTED BY .... -------- -•. ---------. DATE ----�/-^'---7 <br /> BUILDING PERMIT ISSUED _..-------•---•------------------ -------•-------- ---------------------------- ------.._..DATE <br /> ADDITIONAL COMMENTS -------- --- ................. <br /> I - ---- <br /> -4— <br /> - -- <br /> .------------- ----- ---------- - <br /> 1 inai Inspection by: - -- --. ._\._... ----- ------Date .. :.. r .�---...__._ <br /> C <br /> EH 13 2h 1--68 Rev. SAN JOA UIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> Er <br />