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FOR OFFICE USE: �_� Com , <br /> . ; PLICA IQN,FOR.-SA ITATION PERMIT <br /> --- <br /> = "' Permit No: w- W. <br /> (Complete in Tnpliccitel <br /> ----------------------------------------= //- <br /> _-------- This Permit Expires 1 Year From Date Issued Date Issued __ -"- `I <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 /> i.J . ice.oSs�J�4 r.. J • l� � 23 9-oz�- �3 <br /> JOB ADDRESS/LOCATION . ���- f-U)...... `� -------------------------------------------CENSUS TRACT _r ' <br /> All <br /> Owner's Name ----W�_c= I���y------- -=------- Phone <br /> Address ---------------------------------------------------------------- ------------------------------------------ City. WW ---- --------------------------------- <br /> Contractor's <br /> ------------------------- ...Contractor's Name - --------- '`-'` - ------------------------------------License # ------- Phone ---- <br /> Installation will serve: Residence ff-x—partment House❑ Commercial ❑Trailer Court- ;E] <br /> y <br /> Motel ❑ Other ------------------------ � } <br /> 47ANumber of living units:____.___ Number of bedrooms __ ___Garbage Grinder -- Lot Size ______ ___ ----------------- <br /> Water Supply: Public System and name --------------------------------- ------------------------------------------------------------ ---------------Private)v <br /> Character of soil to a depth of 3 feet: Sand'V Silt❑ Clay ❑ Peat F] Sandy Loom ElClay Loam ❑� <br /> Hardpan ❑ Adobe ❑ 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 <br /> p seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' Size-_---y:� -�__ -�"--P------------- Liquid Depth _-��-________,__.- <br /> Capacity __.tfl_„ Type __ - MaterialNo. Compartments. ___...-----. <br /> r Pro Line ____ <br /> Distance to nearest: Well _--_ Foundation ___� .____.____- _ p. .�------------- -� <br /> LEACHING LINE [ ] No. of Lines -------3------------- Length of each line______ 6--__-------- Total Length _____j _ <br /> t. <br /> D' Box tS- Type Filter Material -_��_-Depth Filter Material -_-,_.l _______________________________ <br /> _ .`Distance to nearest: Well"'�•_�LaCa___-'-_-- Foundation -------------------- -- party-Cine ----:-_----- <br /> I <br /> SEEPAGE-PIT-- -Depth�-----:_.--:-:=-- Diameter -=-Number-------------------------- -Rock Filled -Yes ❑ -. No-.G— <br /> WaterTable Depth --------------------------------------- -------Rock Size -------------------------------- <br /> Distance to nearest: Well----------------------------------------Foundation -------------------- Prop. Line -----------.__........ <br /> REPAIR./ADDITION(Prey. Sanitation Permit# _____________________ <br /> ---------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------- ---------------------------------------------------------------------------------------------------- ------------------ <br /> DisposalField (Specify Requirements) --------------------------------------------- --------------------------------------------------------------------------- ----------- <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: <br /> "I certify that in the perform6nce'of the work for which-this permit is issued;1-shall not employ any person in-such-manner - <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----- ------------------------------------- Owner <br /> wB ------ Title ---- <br /> ------------------- ------------------------------------------------ <br /> (if <br /> ------- ----------------------------- ------ <br /> E <br /> (If other oer( <br /> FOR DEPARTMENT VO,ON Z. r <br /> APPLICATION ACCEPTED BY ------------------ DATE ,- `_a �'_ 'l_ <br /> - . <br /> BUILDINGPERMIT ISSUED ------------------------------------- ----------- ----------- ---- --------- -----------------------DATE -------------------- ---------------------- <br /> ADDITIONALCOMMENTS ----------------------------------- ---------- ---------------- --------- - -------------------------------------------=:---=-------------------- ------ <br /> ---------- -------------------- -------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- <br /> k <br /> ------------------------------'" --------------------------------------------------------------------___------------ _ - <br /> _____________________________________________________________________ ;orf <br /> Final Inspection by: ---------------- ----- ----------------Date ---3 --------k---------------- ------- <br /> SAN JOAQUIN LOCAL HEALT ISTRICT " <br /> a <br /> E-`H. 9 1-'b8 Rev. 5M <br />