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s APPLICATION FOR SANITATION P' OMIT <br /> ............................... <br /> (complete In Triplicate) f Permit No. .7! 72 1 <br /> f' This PeAnit Expires 1 Year From Date Issued Date Issued _ f�.7.. <br /> ..... ........... $......... .... ...........:. <br /> Woo <br /> Application Is herebymade to the San Joaquin Local Health District for' a permit tostruct and Install the work herein <br /> described. This application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulationsi <br /> F//-7 9.�7�/ 'Z -. ... ' I /7. CENSUS JOB ADD - i 1!/�.../T '' ! .-.J�d� <br /> SS/IOCATION SUS TRACT ... <br /> f` <br /> Owner's Name ................ ......................... .......... Phone ..7. .`�S/3...... <br /> <kddress �/J - -----------------• ....................city <br /> ty <br /> Contractor's Name . .. .f�!_�.... .. a /L.... License # �f 3��...... one <br />' Installation will serve: Residence A rtmen fuse...._Commercial <br /> ❑ Pa ❑ ❑Trailer Court ❑ � <br />' Motel XOther. . <br /> �. ��` <br /> Number of living units:............ Number of bedraama ..----.--...L;arlsage Grinder Lot Size _ <br /> Water Supply: Public System and name ................................_----........ ............ ....... ..'e- ---- . <br /> votejff C4 <br /> Character of soil to o depth of 3 feat: Sandr] Silt Q Clay,E f Peat❑ Sandy.Loam..+.-..'Clay`Laam [j <br /> Hardpan(] Adobef❑ Fill Material ... If es, ........... ........... <br /> .......-- Y type <br /> (Plot pian, showing size of lot, location of system in relation to wells, buildings, 'etc. must be placed an reverse side. <br /> NEW INSTALLATION: (No septic<fank oriseepage pit permitted Iffpublic sewer is available within 200 feet,) <br /> i <br /> PACKAGE TREATMENT ( ] SEPTIC TANK �Size. ....... ��D��,`7 Liquid Depth .. <br /> Capacity3�C�......... Type 0 �A1 Materiol..00X .`.. Na. Compartments ------------- <br /> partmenta ...� <br /> Distance.'to nearest: Well � t <br /> -,��.......__..-•---........Foundation ..,�Q............. Prop. Line . <br /> `EACHING LINE (4---No. of Lines .,3...........I...... Length of each line Q 1.7��..`�Qr' Sia <br /> 9 .� Total Length .. .r ..` <br /> 'D' Box .::An.._`Type Filter Material SU?R k..Depth Filter Material ..../ 8 �� .......... <br /> i Distance to nearest: WeII .� t.... Foundation ...9?©.. ......... Property Line <br /> ' . ............... <br /> .. <br /> SEEPAGE PIT �l.}/ Depth ......---. Diameter C...Q.......... Number .--••... .................. <br /> `` � Rock Filled Yes,�J' No <br /> Water Table Depth .....fes...... .........................Rock Size . .,?l _ ............. t ^^•. <br /> Distance to nearest AV�... � Foundation ...�� � Prop. Line S. .� <br /> P <br /> REPAIR/ADDITIONSanitation Permit <br /> . (Prev.( � � ....---................................•--.. Date ..._,.................. . ..._ .} <br /> Septic Tank (Specify Requirements) ........... ......,.................._ ..........._,.................»...... <br /> inents) ................ '• .._.M........:.........................._.. <br /> Disoosal Field (Specify Require <br /> ........................•----•........... <br /> ................................•-•--•------•--...------.... .........----............_....._......................... <br /> -- - --------------------- -•-•-- -----.....- ------.-....------ <br /> .......------ <br /> .......................... <br /> ......... <br /> .._....._... <br /> f(Draw existing and required odditlon on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in acoerdance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health Distrht. Horne owner or llcen- <br /> sed agents signature certifies the following: i <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 beta ub act to W an'i Compensation laws of California" <br /> .�nec� d) /.. ?........ �O.l_ .� ............... <br /> ....... <br /> *............ Owner <br /> By ....................( . ...- .......G( .._ ...... ...... .. Title �6,� ` <br /> Of other: hon owner'' <br /> t <br /> FOR DEPARTMENT USE ONLY 5 <br /> APPLICATION ACCEPTED BY ...... <br /> C:... .A . ........................................................ DATE ...x'..1.7.. ...:..:........... <br /> BUILDING PERMIT ISSUED .......................... <br /> ADDITIONAL COMMENTS ..-. ...............................................DATE.........---...........-.................. <br /> .......... <br /> ..........................................................................,........................................... <br /> ..........................•-"-..-. .. ....... .- ... ...--......---.....-.......•............--...._.....................-............... .... ... ......... <br /> Final Inspection by. _:- . p . <br /> . � t <br /> ... ... ....................................................................................... ate . ...... .. ...�....................... . <br /> EH 13 2!t 1-68 Rev. 5W SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M <br />