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FOR OFFICE USE: j�APPLICATIO FOItItANITATION PERMIT <br /> v <br /> (Complete in Triplicate) Permit No. <br /> -- ------- - <br /> ..-_.,..- - ----- _ --_-.. This Permit Expires 1 Yew From Date Issued Date Issued .. rz/_:-17� <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 Ordinnaaynncc�e No. <br /> 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ....�Q-7yl�-. ,.!✓4.-�CDQ�---. 5�-!--✓--Lam`-........-- -CENSUS TRACT _-. ____-.-_.._. <br /> Owner's Name ------ .�_�NWZ <br /> 0107.1,S/kz .--------•----------- --- ---- r----•--....................Phone ---- - - --- --- ----------- <br /> ..-- . ..fC .7 ' � h.-?---------------- City 'y lei---------.._...-.- <br /> Contractor's Name .... -5 Aea------------ - - License # -----...- -- ---- Phone - - ----- -- -- -- <br /> Installation will serve: Residence Apartment House C] Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other <br /> Number of living units:....... Number of bedrooms ............Garbage Grinder ------------ Lot Size --------------------- -. --------- <br /> Water Supply: Public System and name . -- ----------- _ ----------- ---------------- .......--.Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay 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.) O <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size----- - --------------- ----------------------- Liquid Depth ..........-.._.___.._,..... X <br /> Capacity ----------- ------- Type .. --_---------� _ No. Compartments ...................... <br /> Distance to nearest: Well -------------------------...........Foundation -----_-----.--------- Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ._._ ____ _---------- Length of each line--------- --------_ .--.- Total Length <br /> 'D' Box . Type Filter Material --- _--------------Depth Filter Material ............................................ <br /> Distance to nearest: Well ------_ ..-_--------.. Foundation ------------------------ Property Line ---_--...---..-_-_.---- <br /> SEEPAGE PIT [ j Depth .............._---- Diameter ._.--- .-------- Number ._ --------__------------- Rock Filled Yes ❑ No C] <br /> Water Table Depth - -- - --- --------- ---------------- ---Rock Size <br /> Distance to nearest: Well ----------------------------------------Foundation ..._................ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..............................._---------- Date .................................. <br /> Septic Tank (Specify Requirements) _ __ ......... -------- - - - ----- -- ---- --- .. <br /> Disposal Field (Specify Requirements) _,06ll�------- ._._1- --- =- <br /> �1.?V..w-.S�p�I.•---------- -------- <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 performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to beco sub' ct to orkman's Com ip laws of California." <br /> Signed - - ---------- --- -- ---- ---- ---- ---------------- - --- Owner <br /> By .. - - - ----- --- -- ----------- -------- - - -- --- --------------------- -- • Title ------- - -- <br /> (If other than owner) <br /> Ae3 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.-_.-. - _. DATE ....�-----------__ _____________ <br /> BUILDING PERMIT ISSUED -•-•-.••------•-----------------------------••-•-•••-•--------.. .. -- .. . . . - ------ -- . .DATE _... ------....--•............._......- <br /> ADDITIONALCOMMENTS - ----------- -- - -- ----.--............................................... ------ --- ------ -- _.. . .. --- . . .....-- -=-------•-------- ---------- <br /> -------------------- ------------ - --••••---•-••••••--••-...........-•-•--•..............•••-------..........------••---•.•--•-•••----................_........_•---••..-••-•-•.-----: ... ------ <br /> .......... ------------ •-•---- -------------------- <br /> ------------------------------------------- <br /> Final Inspection by: . .lu- - Date ... r-�� :. ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />