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FOR OFFICE USE: " # APPLICATION �,OR' SANITATION PERMIT <br /> I Permit No. [c� <br /> F <br /> .. .._�----���- �� �• .,' - '� �`, <br /> (Complete in Triplicate) <br /> M - Date Issued <br /> _----------------- :=f This Permit Expires 1 Year From Date 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/LOC TION kWs_,501_ -----r---J��r _7 _ '��-----:----CENSUS TRACT -----------------•-----,-- <br /> ,Q/ <br /> Owner's Name - - ���-�-----1_ /w��-T ------ ------------------------•---------------- --------------- Phone ----------"�'�..----.......... <br /> r � ,� ........r+,...-.....w�. ._..tea............ ...�,-. r+r�.. <br /> .meq .r� ��--.= City ------------ ----------------------------=---------------------------•------ <br /> Address ---------------/- <br /> - �j� ` ry <br /> Contractor's Namek{-----.------_�__D/�-5----1/VC_.License MEOW/------- Ph ire 4&b_f/W-•--•-- <br /> Installation will serve- Residence ❑ Apartment House❑ CommercialINTrail>rr Court ❑ <br /> Motel ❑Other ------------------------------ ----------- <br /> ber of livinunit ! Q_ Number of bedrooms`-O--_____Garbage Grinder -0Lot Size -----Num ----- <br /> - Private <br /> Water Supply-jPublicSystem andiname t' ------------i---------•----------------------- -----------------�------------------�-----= <br /> Character of soil to o'depth of-3 feet: Sa4d'❑ Silt 0 Clay,[J, �Peot❑E Sandy Loam F]- .Clay Loam .. <br /> ._ I _ -. <br /> Hard pan ❑ Ad6 be.1] Fill Material __-____---- If yes,type ------ ------------- <br /> r t f � � ' - , <br /> (Plot plan, showing size of lot Iocation of s�+stem,,iri, relation to wells, buildings, etc. must�be �pla�ed on �e erse side.) <br /> ' NEW INSTALLATION: (No sept tank or seepage pit permitted If publicsewer is available within 2D0 Alfeet, lr <br /> PACKAGE TREATMENT [ ] SEPT IC TANK% Size---1- ---------------------------- .--------- Liquid pth ------- • ------- <br /> 61 .._. —�— <br /> Capaci _Rev_ Type V -- - _ --- Material,- No.- Compart ents CZ'_ ______________ <br /> _Foundation Pra Line •t•------ <br /> Distance to nearest: Well __%Z'Di�-_�------_--_--':_-- �-Q- - kp' vis <br /> ___ _ line--SV---- ______ Total Length ,-.---- <br /> t � p <br /> LEACHING LINE No, of Lines - Length -r .. s � <br /> T e +Filter-Materia[ �_y --'De th-Filter Material T- , <br /> _�_ _ _____ en th of eac <br /> j D' ,Box <br /> -�` ---- Yp v o , ��. a <br /> Distance to nearest: Well _�s - ------ Foundation -- _ --- ------ Property Line ___ <br /> ' SEEPAGE PIT f ] Depth ------------------- Diameter ---------------- Number :.----------------i--------- +Rock Filled Yes ❑ No 0 <br /> t 1 Water Table Depth __-_----- r� <br /> -- ---------------•-------Rock•Size -----�-------- --------------- <br /> 1 Distance to nearest: Well --------------------I--------------------Foundation _i_____--_____.__- Prop. LineREPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date - -----------#-• -------- -----1 <br /> ' 1 <br /> Septicl ------------------ <br /> Tank (Specify Requirements) . ---------- ------------=------------ - <br /> = - <br /> Disposal Field {Specify Requirements) --------------------- ------------- ---------------------------"=---- ----- <br /> ---------------------- <br /> - <br /> ------- <br /> ------------------------- <br /> I <br /> ` <br /> --------'---------i---------------.----------------- ---------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby c�rtify that I have prepared this application and that the work will be done in accordance with Sart Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San .Joaquin Local Flealth District.'Hzome 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 no employ any person in such manner <br /> ---. as to becom s ject to-Work <br /> 's Compensation laws of California." <br /> . - or" <br /> i► <br /> Owner <br /> Signed -- ------- - ------ =------,----�1------- ----- -- ------;--- - r . <br /> 6 Title _. ------------- <br /> Y"„ ------ "'t' -------- <br /> "( other than ownei} ,�`a <br /> - FOR DEPART T O Y L <br /> APPLICATION ACCEPTED BY -------------------- ------------------ ---------- --- ---- -. DATE - - ' -' --. <br /> BUILDING PERMIT ISSUED ----------------------------- ._ --------DATE- --------_-------------------------------- <br /> "� <br /> ADDITIONAL COMMENTS ------------------------ <br /> I ------------------------------------------------------------------ -- --- ------ <br /> &DIRICT <br /> ------------------------------------------------ <br /> Final Inspection by: -------------------------------------------------------------- - ------------.Date - -------- <br /> - - ---------------=- ----- -- <br /> SAN JOAQUI ' LOCA EALT <br /> E. H. 9 1-'68 Rev. 5M <br />