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.J%rrLt%,A11V1M rVK 5APHIA11V1114 FtWIT <br /> lComplete in Triplicate) <br /> Permit No. <br /> ............................. <br /> • DbDablisutA 7 <br /> ........................•.............................. This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permitto construct and Install.the work herein <br /> described. This application Is made In compliance with Cou ty Ordinance No. 549 and existing Rules and Regulations, <br /> JOB ADDRESS/LOCA <br /> �TION .. ...........I.......... ....................... <br /> .. ..... .:...............................CENSUS TRACT ......................... <br /> ........... . ..... ................................................. ..................... <br /> Owner's Name ....Phone ...f-f �Ll_ <br /> Address _ _- ---- --- ----- ---- .................... . ....................................-City .................................... <br /> Contractor's <br /> . . . •..............................................ticense:�__�_ <br /> Name ---- F r.. Phone <br /> Installation will serve, dance aApartment House 0 Commercial[}Trailer Court 0 <br /> Motel0 Other........................................... <br /> Number of-living units:............ Number of bedrooms .5......Garbage Grinder ...... ..... Lot Size ........................................ <br /> Water Supplyi Public System and name .................-.......................................................................... <br /> ............_Private er <br /> Character of soil to a depth of 3 fe'et. Sand 0 Silt 0 Clay -0 Peat 0 Sandy Loam (3 Clay Loom [3 <br /> Hardpan[3 Adobe(3 Fill Waterial ...... If yes,type...... ....... ............ <br /> (Plot plan, showing size of lot, location of system :In relation to wells, buildings,.etc. <br /> must be placed on reverse side.) <br /> NEW INSTALLATIONt (No septic tank or seepage pit permitted If public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT SEPTIC TANK( -size................................................ Liquid Depth ........................ <br /> pe <br /> ... . .. I <br /> Capacity/29", Material...................... No. Compartments <br /> Distance to nearest. Well <br /> Foundation .......... ........... Prop. Line .................... <br /> ..,g. ....... ....... <br /> ff----_--_------- Length of each 11 e.7 <br /> 'LEACHING LINE No. of Lines n *.................... Total Length ...............-NX <br /> V Box J------- Type Filter Material .....Depth Filter Material / - i <br /> ............ ...................... <br /> Distance to nearest- Well ......... .............. Foundation ......................... Property Line ................. <br /> SEEPAGE PIT, Depth .............. Diameter ................ Number ............................ Rock Filled Yes 0 No <br /> Water Table Depth ................................................Rock Size ....... <br /> Distance to nearests Well ............................4...........Foundation -------------- Prop. Line ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements.) ................ -•...__................. ......................---.............--••-.......... ....... <br /> ........... <br /> Disposal Field (Specify Requirements) ................ ................................... .................................. <br /> -7-------7--------7--- ........ <br /> ........................................................................................ .......................... ................................. ....... <br /> ............ --------- <br /> .......................................................... ......... .......... ....................... ........ .................. <br /> *----------- -------- <br /> (Draw existing'a;�i-required'add'iii�;-,o--n"r"s,verse side) <br /> -o-j I hereby certify that I have prepared this application and that the work will be done In accordance with Son.Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or Men- <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 tobecom subject to Workman's Compensation laws of California." <br /> Signed .............. ................................... Owner <br /> By .............. ..................................... <br /> (If other-than ownerl <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> .............................................. ........ ... DATE .... <br /> BUILDING: PERMIT ISSUED ...... ................. .................... . ..... .................. <br /> . . ...... ..........MATE . <br /> ADDITIONALCOMMENTS .............................. ...•-•.......•---....__......_.-.•------_-.....__._........_... <br /> .............................................................. ......I.................................... ......... <br /> ...............•-•-----------.....----------------------....._.......-----•--. <br /> ...........*--------------------------------------—---------------**....*-**-**-----------*....................... .................... <br /> .­­......... ............................................ .............­­......­­... .................... ................. <br /> Ina I io-n...b"y-:........................ ...........-,.......... 9 <br /> EH' 13 24 1-68 Rev. 5H ...............1-1..................... Date ....:. -:........_.._-_--•-------------•- <br /> SAN JOAQUIN LOCAL HEALTH Oil 3M <br />