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A0irklCATiON it Ok SANIYATI N P fiY -7 <br /> ............................... Permit ... <br /> (Complete In Triplicate) P It No <br /> .............. ........................................ This Permit Expires 9 Year From Date Issued u <br /> Pnd. <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to c sail a work herein <br /> described. This application Is made In compliance with County Ordinance No. 549 an existing Ru egulatlonsr <br /> f <br /> ..._ .:. .....CENSUS TRACT <br /> E JOB ADDRESS/LO TIO t. �� �.... -. X. -. .%! F� .......................... <br /> ..� :..,..� �2.C.: ...Phone .......... .. <br /> Owner's Name .._..----•..................................................................... <br /> Address ....................... ....................................................... City ........... <br /> .................~_ <br /> -....------•--........................ <br /> .... <br /> J w a 1y <br /> - ------- -----------------•-..--.- .......Contractor's NameLkense <br /> installation will serve+ s1dence partment House 0 Commercial OTroller Court ❑ <br /> Motel ❑Other ............................... ------------- <br /> Number of living units------------- Number of bedrooms .�9_._..Garbage Grinder ............ Lot Size .................. ------------------------- <br /> Water Supply: Public System and name ---------------•_.__.- _.____­.___-____...... .................................... .._.Private [1�--- <br /> Character of soil to a depth of.3 feet: Sand Silt❑ Clay ❑ . Peat❑ Sandy Loom ❑ Cloy Loam ❑ . <br /> f 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 seepage pit permitted If public sewer is available within 200 feet) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size.... . ..........•............................ Liquid Depth .......................... <br /> ,y- f <br /> I P. <br /> ;Capacity% c ! �yp7�.----- _= Material...................... No. Compartments ..�._........_.� <br /> Distance to nearest: Well -fQD:-..-_. ...... .....................� <br /> LEACHING LINE [ ] ` No. of Lines g <br /> -....� _-_ Length of each Ilne...X0 � <br /> ----------•----- ........................ Total length ��..................... <br /> 'D' Box .1........ Type.Filter Materia! Depth Filter Materia!' <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT [ ) Depth .. ............. Diameter ................. Number ............................ Rock Filled Yes ❑ No <br /> I <br /> Water Table Depth -------------------------------------------------Rock Size ........................ <br /> Distance to nearest: Well ----------------------------------------Foundation .................... Prop. line .................... <br /> REPAIR ADDITION(Prev. Sanitation Permit# ....._-_---------------•-------------------- Dote ---------.........................) <br /> SepticTank (Specify Requirements) ...........................................................................................-.......---•--•--............................... <br /> Disposal Fiela (Specify Requirements) ------------------------------------r..........-...-.......................... <br /> ...........................................-----_....- .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. Horne 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, I shall not employ any person in such manner <br /> as to become subject to Workman's C�,qmpensafion laws of California." <br /> Signed ..... `- <br /> / . Owner <br /> By ....................................................................................................... Title ................................................------.................. <br /> 5 <br /> Of other than owner) <br /> FOR DEPA ENT U_U ONLY <br /> APPLICATION ACCEPTED BY ...... ...... . ....`�' -. ............ DATE .. r <br /> BUILDING PERMIT ISSUED .........:......... .. -- -- ..........-...... ....-. .....DATE ........................................... <br /> ....... ........... <br /> ADDITIONAL COMMENTS :........................ ..................................... <br /> ........ <br /> ..................... .................... .......•-- ............. . ...-... .'. ........... ...... .... '.... ---................................... <br /> ' .................... ......... <br /> Fina1 inspection by: .......... ... 1C �...`... ........ . ................Date .. /.. <br /> ii ) 1-66 � �/ _.... �........ <br /> !� 5N SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />