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JFOR OFFICE USE; /� AP ' 1CArlON t~AR SANIrAri�N PERdiR►!rper 73—3, <br /> iCamplete in Triplicate) <br /> Date Issued` S'� <br /> ./ I <br /> This Permit Expires 1 Year From Date Issued <br /> ork herein <br /> Application is hereby made to the San Joaquin Local Health District jnarnc Nom5a9 a d exist ng Rulesit to construct and taind.It gulat onss, <br /> described. This application is made in compliance with Cou y n <br /> 1. I...:...... . ..:................. . <br /> ~ .........................^ <br /> ..... .. CENSUS TRAP <br /> JOB ADDRESS/LOCATION ......... _ - ../... f..•• •� <br /> ..•�........^ ne............ ............... <br /> Owner's Namer. = �` ` <br /> Address _... .�...�...... ��--....... '� _.`.....:City Ph .-f <br /> .. <br /> r C if one <br /> � <br /> Contractor's Name .....� c` !A ��: ���.��.License � .. <br /> Installation will serve Residence []Apartment House 0 Commercial []Trailer Court $] <br /> Motel �*Other ............................... <br /> Garbage Grinder —Lot Size ... .....,.2....-�.� �, ] <br /> .... <br /> Number of bedrooms .g •••• "'• <br /> Number of living units. •.. "' <br /> � t .........................Privy <br /> to <br /> Water Supply. Public System and name CiaY... .............""- .Peat'❑ Sandy Loom C] Cloy Loom m 0- <br /> Character of soil to a depth of 3 feet- Sand {] Siit Q ._, <br /> Hardpan ❑ Adobe '[�j Fill Material If yes,type ......................... .. <br /> in size of.lot, location of.-systern in relation to wells; buildings, etc. must be placed on reverse side.l� <br /> (Plot plan, showing � d <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet) - F <br /> `f .......... ....................... . Li Liquid Depth <br /> -._....................... <br /> PACKAGE TREATMENT SEPTIC TANK-f �ze.......: <br /> ....�-..—• p ...:.................� <br /> Capacity. ................... Type _.......---......... Materiai.........---....... No. Compartments <br /> ' Foundations Total Length <br /> line <br /> Distance to nearest Wel{ ••.................... ............. •.... <br /> ' length of each li e.. ength ..���........ <br /> LEACHING LINE No. of Linea <br /> r , <br /> i Type' Filter Material .:..Depth Filter Material ... �.. .........•. ,.. <br /> 'D' Box .:. . <br /> .. f <br /> r <br /> . Foundation Property Line ..... .....•_•........ <br /> Distance to nearest: Well -•.....•• <br /> Depth s . Diameter *T f� Number .......c ................ Rock Filled Yes, ' No ❑ <br /> SEEPAGE PIT �(j .'�...•... .: ....... <br /> I ,........Rock Size .. <br /> Water Table Depth ............................ <br /> ...................Foundation ��/......._ Prop. Line . -............ <br /> Distance to nearest; Well _..,�ti?.�1�.••••• "" '"- ` <br /> _ <br /> REPAIR/ADDITION(Prev. Sanitation Permit ..•.••.•••••-•••• <br /> Date ..................................y <br /> ............. <br /> Septic Tank (Specify Requirements) .....................................-..' <br /> Disposal Field (Sp cify Requirements) ....... ......•• <br /> ��--� .. :. ...... •. �`� :-':....tea` <br /> ....................................................................... <br /> (Draw existing and required addition on reverse side) <br /> It will be done In accordance with San Joaquin <br /> I hereby certify that I have prepared this application and that the war ` <br /> oaquin Local Health District. Hams owner or Ilcen- <br /> County Ordinances, State Laws, and Rules and Regulations of the San J <br /> sed agents signature certifies the following: person in such manner <br /> "I certify that in the performance of the work for which this permit is issued, I shall not omploy any P <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ,...... ............. Owner <br /> B ..� ....--...... Title ........ .. .. ............... <br /> Y •• r. . .�..__ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY ` <br /> APPLICATION ACCEPTED BY .-I: .. .... .........I........................ <br /> DATE ... ......... ..... <br /> BUILDING PERMIT ISSUED .......................... <br /> ....'..:...... ...................... .................................DATE ........................................... <br /> .. <br /> ADQITiONAL COMMENTS .......;'............ ...4..................._........... :...... <br /> :.............. ............:.-.......•......... ::..... . ....._........................._................_ :.....:..:... �� ... <br /> .. ........ •• <br /> .....-••_..... J,. .............Date .............. <br /> f=inal Inspection by: ....... <br /> ... .r .. F <br /> SAN JOAQUIN •LOCA EALTH.. DISTRICT � <br /> 7172'3 M <br /> 1 'i 94 , Ise n___ rag <br />