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FOR OFFICE USE: .APPLICATION ICOR SANITATION PERMIT <br /> -- 1,11.9L)_...� --••--•---•- Permit No. __- �_�IV <br /> (Complete In Triplicate) ,; 3 <br /> This Permit Expires 1 Year From Date Issued bate Issued .................... <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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION j°a:: �.l�e•.(�?.... � �:= d ' f'e ..........CENSUS TRACT ............. <br /> Owner's Name ., .� _ / � .. ...... ............ <br /> / ......... :............ Phone <br /> o - city . '6l �r --' <br /> Address . ••kv� ....... .. ........................••-•-....-•-.......-. <br /> Contractor's Name . ��...; '�l� .......................... _. ..License-#�,�f�z��.. Phone �� .. ...... <br /> Installation wilserve: Residences Apartment•Housefl CommerciaMTrailer Court'❑ <br /> Motel ❑Other .._k....`::' -............. <br /> - <br /> Number of living units:-.../..-. Number of bedrooms . _ ......Garbo e.�Grrntier• . _ ,,...; Lot Size .7 _Xr�f-'-•fes• •••••••••••--- <br /> w <br /> Water Supply: Public System and name � ,,t`.. f_._ ► '!�!__ ............. Private [} <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑�C!y ❑ Peat.❑), Sandy Loam 0 Clay,t.00m ❑ <br /> Hardpan(] Adobe O] Fill Material........... If yes,type ............... ............ <br /> . ter: ' <br /> Mot plan, showing size of lot, location of y tem in-'relation torwells, buildings, etc. must be placed on reverse side.) <br /> NEW'INSTALLATION °•(No-septic tank or seepage, pif perrrlffed If public sewer,.is avaifabl_e within 200 feet,) <br /> PACKAGE TREATMENT ] SEPTIC TANK I ] Size.... ......... Liquid Depth <br /> -.....:. <br /> ..........Capacity Type .... ----- Material. ......... •....... No. Compartments <br /> -.,;r Distance to—nearest: Well ---------__________ -_Foundation <br /> •--------•---•--• ...................... Prop. Line ....... .............. ; <br /> LEACHING LINE (`j '. No. of Lines ................. Length of each line..................... ...... Total Length ...................... <br /> -_:..'D' Box ------------ Type Filter Material ....................Depth `Filter Material ........................................._1 r <br /> Distance to nearest:. Well .....................__. Foundation .............. ......... Property Line ...................... <br /> SEEPAGE.PIT ( ) -IDeoth ....................... Diameter ................ Number .................. _........ Rock Filled. Yes.0No.l� <br /> Water '.fable Depth Rock Size <br /> Distance to nearest: Well ........................................Foundation ................. Prop: Line ..................... <br /> i REPAIR/ADDITION(Prev. Sanitation. Permit <br /> ..................-......................... Date .--•• .............. r <br /> - k . <br /> Disposal Field (SrecEf Re uirements)- •. '............ .. _. ....�........-•-----rJ--..:..._..._.....................................---..._...... <br /> Septic Tank (Specify Rectuirements-.:.:: ._ <br /> ------------ <br /> ----------------------___---------------_-----------------___________________________________________________-_......_-____-._______-_.___._..:.....__.__.._...._..____.-......, <br /> ___�wraw existing and required addition on reverse side) <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:Dlstrict. Rome Owner or licen- <br /> sed agents signature certifies the following: r <br /> "I certify that in the performance of the work for which this permit is issued, I %hail not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of Califernia."__,-. <br /> Signed -------------------- ------ ------------- - ----------------•--•-------- Owner <br /> By -------------------------------- ----- ��' "----._.----.. .......... <br /> lif oche an„owner) * <br /> R DEP MEN LIWONLY <br /> APPLICATION ACCEPTED 13 - 1"i`" DATE .._lv ��.-----?,5............. <br /> BUILDING PERMIT ISSUED" ----------------­--- ----------- '-.... -------------=--... DATE _..-_.:...- <br /> C ADDITIONAL COMMENTS ------ - - _--•- .. ..: ..--•-•------------• ---------------- ........ ..................... .................. <br /> ------------•-•- ....-----•.................................. <br /> ---_ •----------- _ .............. -'__ ..),......._._.--.. 4. <br /> _ <br /> r <br /> Final inspection by: v <br /> ` ------Date­ . �. .-: <br /> j EH 13 24 1-68 Aev. 5�i SAN JOAQUIN LOCAL HEALTH DISTRICT ,..$�7lt 3M <br />