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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIL, <br /> ----------------------------- Permit No. Z77r_,------- <br /> Complete irf-Triplicate) <br /> ----------------------- -------------------------- <br /> Date issued <br /> ---------------------------------------- i This permit Expires I 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 madiflin compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> ------- 31------ ----------- --------------- <br /> JOB ADDRESS/LOCATION 0 ---------- --------------CENSUS TRACT --------- <br /> Owner's Name ----- ca4 - Phone <br /> -------- --------- <br /> ----------------- - ---- ------------------------------------------ <br /> Address ----- 'a_t19 Z_ - <br /> Contractor's <br /> ------- ----------• city --- <br /> r j <br /> _a_y1,K*------.License # Phone 2W�Z:n2la4k- <br /> Contractor's --------S__1411P---t;_c----f, I <br /> Installation will serve:. F-JTLqLile <br /> Residence Ea Apartment House�El Commercial r Cp.LLrt_0 <br /> F Motel F-1 Other -A--_- ---- - - ----- - ---------------- <br /> Numbe�, of living units:_______ Number of bedrooms L-9----Garbage Grinder. ------------ Lot Size <br /> -----------------------NI <br /> Water Supply: Public System and name ----------------------- ------------------------------------------ -------------------- ------------- ---Private Pr <br /> Character of soil toga-'depth of 3 feet: Sand'E] Silt❑ Clay E] Peat 0 Sandy'Loam -0 Cloy Loam E] <br /> Hardpan [`J__Adpbe >1 Fill Material ------ If Yes, type ---I---------I--------------- <br /> (Plot plan, showing size of lot, location of7syst6 in' relation to wells, buildings, etc. must'1-6e placed on reverse side.) <br /> 11-1, 1 ._0 <br /> NEW INSTALLATION: [Na septic tank or seepage pit permitted if public sewer is avaitablor-Within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK f,,] Size----------------------------- ----- -------- Liquid Depth -------------------------- <br /> ;Type --- ---------------- Material--- --------- No. Compartments ----------------------00 <br /> ---------------------- Prop. Line -----------_-------- <br /> Distance to nearest:,iwel ------------- ----Foundation�rf - � X <br /> LEACHING LINE No. of Lines .'______r,-____ ._ZLehgth of�ceci&-Ilne--------------/ <br /> -------------- Total Length ----------- ---------------- <br /> 'D' Box ------------ Type Filter Material;__. ______-Depth Filter Material ---------------------------- --------- <br /> i -------------------- Property Line --------- --------- <br /> Distance to nearest.%WPIV------------------------- Founclatior ---- <br /> ------- Rock Filled Yes E] No C] <br /> SEEPAGE PIT Depth -----4 k_'!---- Djam.efer ---------------- Nu6iber .2 ------------ <br /> Nk. <br /> Water Table-Depth'.- --------------------- <br /> Rock Size <br /> ----------- -------------------------------- <br /> ky., ------------ --------- ---------- Prop. Line ----------------------- <br /> - c 'n I " - <br /> Distance earest..'Well --------------------- ------ Foundation <br /> 0 <br /> REPAIR ------------I-------- <br /> /ADDITION-(Prev. Sanitati6n,,Permit# ---------- ,Date --------------- <br /> ----- ----------- <br /> ---------------------------- <br /> Septic Tan'ViSpecify Requirernefftsj+-___.___________--------------- -- ------------- --- --- --------------------- <br /> I I A0 ----------- <br /> Disposal Field (Specify Requirements) -------- -------- <br /> ---------- ------------------------------------ ------- <br /> ------------------------- ------------------------ <br /> ------------------I <br /> -------------------------------------------------------- <br /> --------------- --------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certiN,that I have prep red this appfapplication and that the work will be done in accordance with San Jacquin <br /> County OrclinanceOS.tate 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 p �rformance 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 /> x <br /> By ---Lq - -- -------- --------------�j------------ Title ---- ---4sx-�_ _ --------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> �----------------- <br /> APPLICATION ACCEPTED BY -- --------------------------------------------------------------------------------- DATE A Q1_-AO <br /> --- ----- <br /> BUILDINGPERMIT-ISSUED----- ----- - ---------------------------- --------------------___-:-----.-_.-----------------_----_--DATE ----------- ------------- -------;-------- <br /> ADDITIONALCOMMENTS -------- -------------------------------------------------- -------I-------------------------------------------------------------------- ---------• ------ <br /> ------------- ------------------------ ------------`----------------------------------------- ----------------------------------------------------------------------------------------- ------------------ <br /> -------------------------------------------------I------------------------------------------------------------------------------------------------- ------------------------------------------------------ <br /> ------------------------------------- --- - -- --- ------­------------------------------------------------------------------------------- -------------------- - -------- <br /> ------------------------------------------------------___------- <br /> Final Inspection by; -------- ---------------- ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />