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FOR OFFICE USE: APPLICATION FOP. SANITATION PERMIT <br /> ,/ FOR <br /> 155 <br /> --- Permit No: ----- <br /> (Complete in Triplicate) <br /> --------- -------/J1-A I V_- ----- Date Issued <br /> - - --------- 4 This Permit Expires I Year From Date Issued <br /> Y13.2�v 1 — <br /> Application is herebyAcide to the San Joaquin Local Health District for a permit <br /> mit to construct and install the work herein <br /> On <br /> I. ' <br /> described. This application is made in compliance with Co ty,'Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ----------------------- --CENSUS TRACT -------------------------- <br /> ----- <br /> L/2- ------------------------------- - -- 10- - <br /> Owner's Name <br /> ------------------------ <br /> ------V-A-----t4s,­ ---------- - <br /> V\ <br /> Address ----------------------- ---- ------------------- ity ----------------------- ---------------- <br /> I ------------ Phone - ffContractor's Name --- -----f -- 7 <br /> Installation will serve: <br /> Residence Apartment H us-f-ILL Commercial :[]Trailer Court E] <br /> Motel F1 Othbr -----------------`-------------------------- ff <br /> Number <br /> --------------!-------------------------- <br /> Number of living units----- ------- Number of bedrooms ----7-77--Ga bageS Grin Lot Size ---------- <br /> ------------------------ <br /> Water Supply: Public System and name -------------------- ------------Private El <br /> Character of soil to a depth of 3 feet..N,86'nd Silt 0 Clay 'E] Peat[D Sandy Loom E] Clay Loom Z) <br /> ' <br /> Hardpan obe liFilaterial ------------ If yes,type __.------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENTSEPTIC TANK f ize----------------------------------- ------------ Liquid .Depth ---------------- ,J <br /> Capacity ------------------ Type -------------------- Material---------------------- No. Compartments --------- <br /> V�i <br /> Distance to nearest. Well -------t---------I-----------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE No. of Lifidg-77777=!!---------- Length of each line.--------------------.__-__ Total Length .--__---_.-.--.-____-.._•._ <br /> 'D' <br /> -----------_-------------- <br /> 'D' Box ---------- Type Filter Material--I---- ----------- Depth Filter Material ------------------------------------------- <br /> Distanceito nearest: Well --------------- ------- Foundation ------------------------ Property Line ------------------------- <br /> SEEPAGE PIT Depth1.1---------------- Di Number --- ----- -- <br /> -------------- - Rock Filled Yes El No C <br /> ---- I a -- <br /> WaterTable Depth ---------------------------------------•------I-Rock Size -------------------------------- <br /> Distance to nearest. Well --------------------------------------[Foundation --------------`IW----- Prop. Line -------- ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit ------------------------------- ---- ----- Date—-------------------------- - --- <br /> ---------- <br /> Septic Tank (Specify Requirements) ------ ------ ------- <br /> ----------------------------------- ----------- <br /> - ------ -------- <br /> Disposal Field (Specify Requilrements) -------------1. 3----X -- <br /> _� ------ __ <br /> -_ ;_ <br /> I I I ---i---------------------- ---------------------------------------------- <br /> ------ ----------------------------------------------- ------------------------------------------- --------------------- <br /> I I __!---- :I-Q---------- <br /> ----------- ---------- •----------------------------------------------- <br /> r <br /> ----------------------------------------------- <br /> --------------------------------- -- ------------------------------------------------------------ �0 <br /> (Draw existing and required addition on everse si e) <br /> I hereby certify that I have prepared this application and that the work will be cloQ in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health 'District. Home owner or"licen- <br /> sed agents signature certifies the following- Ii <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 to become subject to Workman's Compensation laws of California." <br /> Signed ----------------------------------------------------- Owner <br /> ---------------------------------- <br /> ------- ------------------- Title .... .......... <br /> By --- ------------- -- ---- <br /> (I of r an owner) <br /> FOR DEPARTMENT USE ONLY <br /> ------------------ <br /> APPLICATION ACCEPTED BY ----- ------- %-------------------------------------------------------------------- DATE <br /> BUILDING PERMIT ISSUED ------ --)-- ----------- ------DATE -------------------- ---------------------- <br /> - --- ---------- ------------- - - - -------- <br /> ADDITIONAL COMMENTS - -- ---- ---- -------------- - - --- <br /> TPI-e_ <br /> ---- - ----- - --- ------ - <br /> ---- ------------- - <br /> -------- ---------------------- ----------- - -------- <br /> ---------------------------------------- ---------------:--------------------------- -- --- --------------------------------------------------------------------------------- <br /> ---------- <br /> ---------------- ------------------------------X'��-------------------------------------------------------------------------------------------------------------- <br /> FinalInspection by.. ---------------Cf------------------------------------------------------------------ --------------------------------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />