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C <br /> FOR OFFICE USE: <br /> ---- - <br /> -------------------------------------- PLICATION FOR SANITATION PEWS <br /> .................... -(Complete in Triplicat'e) Permit No. <br /> - <br /> -------------------- -------- -------------------- This Permit Expires I Year F Date Issue --- --------- <br /> rom Date ....... <br /> Application is hereby made to the San Joaquin Local Health District for a perm k14+_4 QrPt anVinstall the work herein <br /> described. This application is made in c6mpliance with.County Ou dinance No. 549 and existing <br /> Rules and Regulations: <br /> JOB ADDRESS/LOCATiON ..__;/­_0,__V---�g <br /> ---------------CENSUS TRACT ........... <br /> Phone <br /> r.... ........Owner's Name ------ - -6 City... ............. ----------------------------- ----- <br /> Address Za'-Z2 <br /> 46 4& <br /> ----------wx:,:_.� <br /> ---------- <br /> ................ ......I.......... <br /> Contractor's,Name ------------- ----------------- -----...ticense # Phone .111W J <br /> Installation will serve: Residence Apartment House C) CommercialCITrailer-Court 0 <br /> M)tel [-] Other <br /> Number of living units:---/---i--- Numberof bedrooms <br /> ff------Garbage Grinder .1----------- Lot Size <br /> Water Supply: Public System pnd name <br /> ------------------------------------------------------­---------------------- <br /> -------_-------------- --------Private <br /> Character of soil to a depth of:3 feet. Sand4 Silt E] Clay El Peat E) Sandy Loom <br /> ❑ Clay Loom E] <br /> Hardpan Adobe E] Fill Material ------------- <br /> If ,es <br /> type ------- --------------------- <br /> (Plot plan, showing size of iot, locatio'n1of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No sleptic tank ci� see I page pit permitted if public sewer is available within 200.feet,) <br /> PACKAGE TREATMENT J] �SEPTICTANKA] .:Size--.,7. -------1A10 40. <br /> i Liquid Depth <br /> Capacity Type Material._6?14� No. Compartments ------- <br /> Distance to neclrestt We ----------� -__...Foundation <br /> Prop, Line ................ <br /> LEACHING LINE' No, of Lines ----- of each line---- Total Length ---- <br /> 1 . , . . . - I /. ---------- ............ <br /> --'D' Box ----/_ ... Ty' e Filter'.�Material /1 10 f <br /> P ------—1------ ...Depth Filter Material ------- <br /> -----IA?....................... <br /> to, neare �001 <br /> Distance <br /> st:.Well.......—------ Foundation ...... Property 'Line ......... <br /> SEEPAGE PIT ' Depths',-..-------------- -- Diameter ... ------------ Number --------------------------- Rock Filled Yes 0 No C] <br /> Water Table Depth --------------------------------------- _...Rock Size <br /> Distance to nearest: Well ----------------------------------------Foundation '---------------- <br /> P Prop. Line .......... ........ <br /> P <br /> REPAIR/ADDITION jPrev. Sanitation Permit# -,................ <br /> i ..............-------------- Date --------------- <br /> Septic Tank (Specify Requirements) ----------------------------------------- <br /> ----------- - ------------- <br /> Disposal. Field (Specify Requirements) --------- <br /> ---- ---------------------------------------------- <br /> -------------------I------------------------------ -------------------L <br />.I i -------214------------- -------------I--­-------------------- <br /> ------------------------ ------------------ i , . <br /> -------- - ­ ---- - - - -- - -------- ---- <br /> Draw x i st ing a-n-d re-q-uired add-i,t,i,a-n__o-----reverse----n ---. s-i-d-e-)----------------------------------------------------------- <br /> I hereby certify that I have prepared�this lop p I icatio-n­-6-ria that 't'he­work will bedone, in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules' and Regulations of the San Joaquin Local Health District. Home owner or [icon- <br /> sed agents signature certifies the following: <br /> "I certify thaf in the performance o <br /> i f the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---- --------------- -------------_1------ ------ -------i-------I-------------------------------- Owner <br /> By ------- <br /> itl <br /> (If other than owner ' -------dlc�_ ----------- ......... <br /> -----------I------ Te <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- <br /> 7,4- - -------------------------------------�:---------- ------------- DATE ---- _5 <br /> BUILDING PERMIT ISSUED _ I ......... <br /> ----------- --------------DATE .- ------------------------COMMENTS --------- -- -- ------ ------- -----------------------------*-----: 1 ------------------------ <br /> k --------- ........... ---------------------------------- <br /> - ---------------------­----I----------------------- ------------------! <br /> i- <br /> --------------------­-- ------------- ----------------------------------------------------------------------------------------- <br /> -------- ----------- - <br /> -------------------------------------------------------------------------- --------•-•------•---- <br /> ---------I----------- ---------------------------------------------------------------------------- <br /> ------------------------------- <br /> -----------I------------- <br /> - ----------- <br /> Final Inspection by----------- ------ ......7-------­------------ ------------- --------- ..... ------- <br /> --------------------------------------Date ..... ... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _!E. H. 9 1-'68 Rev. 5M <br />