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FOR OFFICE USE: APPLICATIOI y'F WtANITATION PERMIT <br /> Permit No. --- ----------------- <br /> (Complete <br /> ---- �____�___ <br /> {Complete in Triplicate) <br /> f <br /> Date Issued _�o ____ _ � <br /> -------------------- ------ ------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 - /. -�- --1� ----------------- CENSUS TRACT _.. p <br /> Owner's Name " r <br /> ' ---- Phone <br /> -- - ---- ------ - ---- - - <br /> �y , <br /> Address �� `-` � ---a---- City -- --------- ------ <br /> Contractor's Name ------------------ ---------------- ---- <br /> .S j? f=----------.License #1.6-P Phone <br /> Installation will serve: Residence%Apartment House❑ Commercial ❑Trailer Court ❑ <br /> r t f6 <br /> Motel ❑ Others t------------f--------- - -------•--- �+/i <br /> Number of living units:_--/------ Number of bedrooms '37:=' Garbage Grinder ------------ Lot Size ....1/0 _______________ <br /> Water Supply: Public System and name -----------------------------------­!------------------------------ ----- -------- --------­----------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ rAdobe Fill Material --- 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 TREATMENT [.] SEPTIC TANK'[ ] O- Size------------------------- ------------------- Liquid Depth -------------------------- <br /> Capacity TYPE ` t Material--------------- ------ No. Compartments ----------------- <br /> Distance to nearest: Well ------------ ----------------Foundation ---------------------- Prop. Line --.------------------- <br /> ---------------- <br /> ------ ------ <br /> s .€.« <br /> LEACHING LINE [ ]; No. of Lines _________ ______-__ -_ ,Length. of each line Total Length .__-_______..-..___________. I <br /> 11 <br /> 'D' Box ------ ----- Type Filter''Material- `-----------------Depth Filter Material -- -------------------------------- <br /> Distance to nearest:Well______________________`__ Foundation ------------------------ Property Line <br /> SEEPAGE P17 [ ) Depth _____ ------ Diameter _______________ Number ___.__._.______- _-______ Rock Filled Yes ❑ No C] I <br /> Water Table Depth ----------------- -----------------Rock Size -------- - --------------------- <br /> D,istarice to nearest: Wel! -----------------------------------------Foundation -------------------- Prop. Line --________------_.._- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ______________ -?- - ,----------- Date _______________._-_____________--1 <br /> ' v` --- -- -------.-------- <br /> Septic Tank {Specify Requirements) :___-___- __-_ _.____ ! <br /> Disposal Field (SpecifRequiremerits) ------------------- <br /> y Cly-.rA--- `--- <br /> -- ------- i -------------------- - -- ------- ----------- ------- --------------------------------- <br /> 1 +�-as' - ------ <br /> f <br /> { q {De existing and required ddition on reverse side) <br /> I hereby certify that 4 have prepared,this-d0#liiatfon-t nd,that-the-work-will be done 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: <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 ---------------------- --- ------------ ------- e--- - ----------------------------- Owner <br /> /` . �►�t�, ------------ title ---- ------------------------------------ <br /> BY ------------------ `"--- <br /> (If other tho ner) ` <br /> FOR DEPAMMENT USE ONLY ��// <br /> APPLICATION ACCEPTED;. BY DATE -Z 7` 7 <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------- -- --------------- --------------DATE ----- ----------------------------------- <br /> ADDITIONAL C MENTS --------- ----- <br /> ----- ------ --- - - ------- ---- -- <br /> ------------------- -- <br /> C <br /> ---------------------- -------- =' ----- ------- -- - --------•------------- / <br /> Final Inspection by: . -- " Date <br /> --- <br /> SAN JOAQUIN LOCAL HEALTH -DISTRICT <br /> e <br /> E. H. 9 1-'68 Rev. 5M <br />