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FOR OFFICE USE: <br /> '-� h--APPLICATION FOR SANITATION PES,_,.IT <br /> Q <br /> -------- ------------- -------------------------------- Permit No. =----� --7-•��-- - <br /> ------------ <br /> (Complete in Triplicate) <br /> - <br /> --------- -- <br /> \� *... Date Issued--` <br /> - --.Z--�-�- <br /> ------------------------- 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 /> 1 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA ��U67 y --CENSUS TRACT --------------•----------- <br /> `'' Q <br /> Owner's Name ---- Phone <br /> ' C1ty 4 t <br /> Address ----------- ---------------•------- --------------------•-----------•-- <br /> 0 <br /> + <br /> lk <br /> Contractor's Name './-• -A-- l _`-O?�s�1 Gt ------License # �fai�,l-------- Phone <br /> r i � ! � 1 <br /> Installation will serve: Residence❑Apartm-ent House❑-Commercial frailer Court.',❑„CL.— <br /> T ; <br /> I Motel ❑ Other -------------------------------------------- <br /> Number <br /> ------------------------------------------Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size -'-- __________________ <br /> I ! ° `Private <br /> Water Supply: Public System and name ---------------------------------•--�----------------- ------------------------ -- ---------------------------- - ❑ <br /> Character of soil to a depth.of 3 feet: Sand'❑ Silt❑ Clay 'El• -Peat-❑ --Sandy-Loam -❑•-s Clay rLoarn 0 <br /> ;Fill Material ------__-_-- If es,type ---------------------- ---- <br /> �„�`; Hardpan ❑ Adobe.� Y , <br /> .,`(Plot'plan, showing size of lot, location of system in relation to wells, buildings, etc. must be' placed oni reverse side.) <br /> r.� <br /> I p see ogee it permitted'-if public sewer is available within 200 feet,} , <br /> ( NEW INSTALLATION: {No septic tank or p, p p <br /> i PACKAGE,TREATMENT [ ) SEPTIC TANK+[ ] _ :r.Size------------------------------ --rte'"tiquid Depth .--- -----------------• -- <br /> I _. <br /> ' <br /> Capacity. , T e = .Mafierial------- --------------- No. Compartments --------------- •----- <br /> T_ Yp w t.: A <br /> } Distance to nearest: Well -------------------- ---------------Foundation ------------------ --- 'P'rop,-Line ----------------­---- <br /> r i. <br /> Ll ACHING LINE- [ ]. No.--of Lines ________________________ Length of each line---------------------------- Total Length ------ <br /> ------------------- <br /> XI <br /> ___ _________...- -.-- <br /> - 'D' Box ------------- Type Filter Material --------------------Depth Filter Material ------------------------------ ------ <br /> - <br /> Distance to nea'rest:. Well ----------------------- Foundation ------------------------ Property Line -----------------_...... <br /> _,. b <br /> I_ Number Rock Filled Yes ❑ No C3 <br /> SEEPAGE PIT [ ] Depth _ Diameter iti <br /> Water Table Depth It _ Rock Size' '$_i------------------------ <br /> Distance I to <br /> ------______-_----- _DistanceIto nearest: Well ------------------------#------- ......Foundation ---------------.---- Prop. Line -----------.--•------- <br /> i( N <br /> REPAIRJADDITION(Prev. SanitatiI on Permit# -------- ------------------- -`'---------- Date ---=-----------------------------1 <br /> \„ <br /> Septic Tank (Specify Requirements) ------=---------------,--- ---- ------------------- ----------------- _16 -------------� - -- `-�� <br /> p Y q � V ,f <br /> Disposal f=ield (Specify Requirements) -_--------�C.ld'�____---�� ------ -----------K-a�----- <br /> I <br /> -------- -- --- --- -- -------- ---------- -- <br /> ! _ -_-- ----�'-��--��-.�w-�.T- -- ------------ -- --- <br /> ---- -- <br /> _ <br /> __[Draw."-sting and required addition on reverse side) [ <br /> I hereby certify that I have prepared this application and thatithe__w,oek will be done inTaccordnnce with San Joaquin <br /> County Ordinances Stat 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 per(o"rrnance of-the woi=k`f WWhiih this permit isissued,"I shall net employ any person in such manner <br /> as to become subject to Workman's Compensation lawst,of California," <br /> ' ' } -------- � � -'----- i <br /> Signed --------- --------- --- ------- ---------- ---- Owner — __ <br /> ------------------ <br /> BY Title' - -- <br /> -- - - <br /> [if otl%er n owner) <br /> DEPARTMENT USE ONLY <br /> 4 -- .4 ------------------------- :,----------------------------------. DATE --------- t 7f-------------- <br /> BUL DIINGOPERM T ISSUEEDBY-_...-----G. �- -=t 1 ="'= k--------- }"f' J---------------------°--------------DATE ------------------ ----------------------- <br /> ADDITIONAL COMMENTS ` ------ r!�--`�-' --------6 ---------------------------------------------_ <br /> N. !� <br /> ' ----- <br /> ------------------------------ <br /> - -------------------- --------------------,__ <br /> - <br /> Final Inspection by. ................................................----------------------------------------Date _ L T <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r E. H. 9 1-'6$ Rev. 5Mj <br />