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FOR OFFI-CE U.SE- ------------- <br /> : APPLICATIOFOIL SANITATION PERMIT- -----'- - -- -- N Permit No. <br /> (Complete in Triplicate} <br /> --- ----------------------_- This Permit Expires i Year From Date Issued 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/LOCATION -�_ 6� �`117n/'�"-_ ----------- - ------------------------CENSUS TRACT --------------- <br /> / yy, Phone 3_� I ��--��rp•-------- <br /> Owner's Name ...... ---------�.f�L�"' -------------------------------------------------------------- --- <br /> ------------ <br /> Address -------- -----A-0 ------- ------------------------ CitY!«' ------------------------------------------ <br /> Contractor's Name __1_, -----------------------------------------------------------------------License # ------------------------ Phone -------•--------------------•- <br /> f ¢Ila i n will serve: Residence M Apartment House-1-1Commercial ❑Trailer Court <br /> vwnl s v�ame _ 4fY 6 or O tee'-r// rH ct oneJL o— �r <br /> Ad �Sit� 4�i / �u �.wIr ��.; t,��Jts ,� ..��' ' -- �;----- <br /> ,f/ <br /> ca vi i i ij :-'----- ..... ---------- <br /> �.�_ <br /> Water Supply: Public System and name -------------------------------•--------------- --------------------------------------------- -------------Private.{] <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam;e� Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation torwells, 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�r; Size___ .zb__,�-6-___________________ Liquid Depth . _Y_______--__,____ <br /> Capacity _«'a_ -------- Type ' -' -G Material______ . -_-._-- No. Compartments _�7................ <br /> Distance to nearest: Well 1(��---------------------------Foundation _1 0-------------- Prop. Line --r----------------- <br /> LEACHING LINE _R] No. of Lines ______---------------___ Length of each line_____�_a----- _ Total Length --16-6---------- ------- 00 <br /> 'D' Box C.u�____ Type Filter Material '_ -------Depth Filter Material ___ ------------------------------- 00 <br /> Distance to nearest: Well __&�_-______________ Foundation _10_----------------- Property Line _ N <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 Z <br /> Water Table Depth ------------------------------------•--•--------Rock Size ----------------- -------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ................__..__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -----------------------------------------------------------------------------•------------------------------ ------ <br /> Disposal Field (Specify Requirements) _--._______. ---------------------------------------- <br /> --------------­---------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- <br /> (Draw 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 District. Home owner or licen- <br /> sed agents signature certifies the following: �j. <br /> "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner "0 <br /> as to become subject to Workman's Compensation laws of California." <br /> � <br /> Signed f -��f --- / /! Owner <br /> BY ---------- - - ----------------------------- ------- ---------- --------------------------------------- Title - ---------------------------------- <br /> ---------------------------------- <br /> (If other than owner) <br /> FO��RDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ___ ____ __? j� � ____.___.______ DATE 27'j-'?'�_'_ `l!------------------- <br /> BUILDING <br /> ___. -_ _:BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------- ------ -------------- --------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - -------------------------------------------------------4-----------------------------------------------------------=------------------------- ------------------------------------------------ <br /> ----------- --------------- - <br /> Final Inspection by , `� �Yl_-tL<'t! -------------------------------------- -------------------------------------Date yl-----" <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r� <br /> E. H. 9 1-'68 Rev. 5M -- <br />