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FOR OFFICE USE vt, • .c° <br /> CATION FOR SA ATION PERMIT <br /> - ------ - x 4_ s Sy . <br /> r ,v (Complete in Triolicate) -� Permit No _ - -.... <br /> ......................... :__ This,Permlf Expires i Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joappin.,k"l,jiealth District for a permit to construct and install the work herein <br /> described. This application is made in.mmpiianoa withrCounty Ordinance No•154�9and ON-eXCENSUS TRACT Regulations: � <br /> JOB ADDRESS/LOCATION _�O,.O-(O....S._.._.�-A R.RQ.4SQ------- ---------h R., T-zEs. > ........ ...... <br /> Owner's Namef-i- f .Phone. ..c✓.. �-.---._ <br /> _-.. <br /> Address ...; <br /> ;i city ........)Rl..PP4.............---- -------.._...........1 -- ..,--._ - Tf! 4� . Yi <br /> Contractor's NcimeS\I..m ...-. <br /> -.License #' .... ..-- - ...--. Phone ---- ... -......:......-- <br /> r <br /> Installation will:server / Residence [4 ,. palment,Houseo Commercial:{3TraileiCourt l] <br /> Motel []Other,_ry.. ... ........ ... . . ... <br /> V� <br /> Number of living units:.....-�-..;N.umber of bedrooms -3.......Garbage,Grinderu.�._-.. Lot Size -JR .R Hri �-_.--...... <br /> Water Supply: Public System dnd ame :.---=•�-`----�',a--,-----•••-- ---t-�------------------------...----------------..............Private <br /> V. <br /> Character of soil to a depth of 3 feet: . Sand _ Silt f Clay ] Peat Q Sandy Loam ❑ Clay LoamE] <br /> iirrdpan p Ailo�i�L] .Fi117NCteridl �.... yes;tyPe--".'."a„- <br /> NI(Plot plan, showing size of lot, location of system IN -1. fion to we�l , buildings, etc-must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seeplige it permitted if public sewer i pvoiiable within 200 feet,) r <br /> PACKAGE TREATMENT ( ] SEPTIC TANK[' Size.;fX1Qrk .Liquid Depth .... ...2.r,---- <br /> 1. <br /> Capacity ..{✓ Q:^l-Type�R FL4B-- Material _ No. cCompartments ...-_7. .c-...-- <br /> Distance to nearest: Weil ......--. 1:. ..:......Foundation -2 ._.-_---'Prop`Aine....4—.. <br /> LEACHING LINE fp}/No. of Lines ----_2 ......... Le th;of eac(itt(ine-_'.�J�$.��T6tal Length _-LA6P.............. <br /> D' BoxxX!�i?-.'.Type Filter Material }3Q K-..Depth Filter Materia( -------/-���:.-.-.---.................. <br /> Distance to nearest: Well. -,: "'r Fiiurida3ior�"--�Cc�. f:- 'PP6(SSrty Line ....J�... ........... <br /> SEEPAGE PIT [ ] Depth ............. Diameter ---------------- N(�r�ber. .... ---------- Rock Filled Yes 0 No Q <br /> . d"4. <br /> Water Table Depth -------- ........................... ---, .Rock,Size <br /> V <br /> { ,( it v... i'-i W44,.3 ` : . <br /> Distance to nearest: Well __;_. .................. ._Foundation ...................:Prdp.-Line .....--...--.--.--..-- <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation P fefmit# -..----..._----------------•...._._.....�A_ Date -.................................) 1 <br /> Septic Tank (Specify Requirements) -......---------- ...................................... ......r-. ---------- - -- ------- <br /> - <br /> V i-- r _ _ __ I <br /> Disposal Field (Specify Requirements) . err - - - ............ I---------------- -------�- ............................ <br /> .......................................... ..... ............................................................ .................... :--.....-------.--...----..-..-_......._........................ <br /> (17ibw existing and required additioSi on reverse 'rs5d1 1"•""- `•""""" <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 Districts Home owner or licen- <br /> sed agents signature certifies the following: , } <br /> "I certify that in the performance of !Pe work for which this permit is issued, I shall not employ any person in such manner .i <br /> as to becom s Wor an' _7om_pensation laws of California." I i <br /> Signed .-. - -- --- --- -- -..--- -- -f- _ u� <br /> --- ----------------------------------- Owner <br /> By ......-'--` . -- - --. .................... :-:-_.......... ....._-...------- Title ' <br /> (If other than owner) v v <br /> FOR DEPARTMENT USE ONLY l <br /> APPLICATION ACCEPTED BY...-.Ti.R.`-q.'...... _- DATE ------------- <br /> BUILDING 'PERMIT'ISSUED-' <br /> - ------ <br /> BUILDING 'PERMIT"ISSUED"` "-^ -DATE- ' <br /> __ .. ..-•--- <br /> ADDITIONAL COMMENTJ �` SY.(- I7�_-.}�4'.Ot ------------------ <br /> _. .. <br /> - - <br /> ----------- <br /> ----------------------- ------ -- -- - 2 <br /> Final Insp _.. . . -------------- --------------------__------Date ------ <br /> SAN JO IN L L HEALTH DISTRICT Rr <br /> it _ js 1 i <br /> E. H. 9 1-'68 Rev, 5M <br />