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FOR OFFICE USE: ( 11CATION FOR SANITATION "R 70_ <br /> X70 - Permit No. .-.----.--- <br /> (Complete in Triplicate) <br /> -------------------. }' ' rr-- -------- <br /> - Date Issued11 <br /> /r _____ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance witch/County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .--- Q q------------lf_ ----�Y-W—y- 1 I--- _CENSUS TRACT 7 6---------------- <br /> Owner's Name -- � 0 1-YEN-�-------------_----------------• ------ ------------------------------Phone -------------- •--._...----•-------- <br /> 1 r <br /> Address ----o-p� ,�, ------ ------ City -------------------------------- _- •�y ---- <br /> 960 <br /> Contractor's Name �_/ •�'�v i Q!` - $� SNC. License # -L `S~� Phone - -------- ------- <br /> Ins"tallation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court :❑ <br /> ff Motel ❑ Other ---------------•--------------•------------- <br /> Number of living units:--__f:----- Number of bedrooms J-------Garbage Grinder ------------ Lot Size ---------------------------_-_------------ <br /> Water Supply: Public System and name -- El: _-_ Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt fl Clay ❑ Peat❑ Sandy Loam (] Clay Loam j] <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.) q <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) C <br /> PACKAGE TREATMENT, [ ] _:SEPTIC,TANK I I . '.. Size.:.. ............... ------------ -- Liquid Depth .--------------------.-••-- G <br /> Capacity ---------------- -- Type -------------------- Material----------- ------ -- No. Compartments --------------••--_- o <br /> Distance to nearest.-Well ---------------------------•--------Foundation --------- ------------ Prop. Line ---------------_...... <br /> LEACHING LINE [ ] No. ofr�-ines -_---- _-- .-_._---- Length of each line_.......------------------- Total Length ..........-.------_.------ -. <br /> 'D' Box ----.----- Type Filter Material -------------_---.Depth Filter Material ----------------------_---------....... <br /> ---- <br /> f <br /> Distance to nearest: Well _---------------------- Foundation p nY <br /> . ---------------- ---- Pro a Line ------.......-----...... <br /> SEEPAGE PIT [ ] Depth --------- ---------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No [3 <br /> WaterTable Depth ------------------------------------------...---Rock Sze ---------------------. -------- <br /> Distance to nearest: Well ---------------------------------------- Foundation ------ Prop. Line ---------------------- <br /> 411 <br /> IREPA <br /> IR/ADDITION(Prev. Sanitation Permit# -------•---------------- --------------- Date ----------------------------------- <br /> Septic <br /> ----•-•--:- --------••-----------Septic Tank (Specify Requirements)`- <br /> ---------------------------------- ----------------•--------------•--------- .-....-------------•---••----- -------------------•-..�----- <br /> Disposal vF.e (Speufy Requirements) id- ---A.. -------�1�►-�J%t-- - , -- -: i r � <br /> i r0 <br /> .. <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, I shall not employ any person in such manner <br /> as to beco subject to Workman's Compensation laws of California."' <br /> Signed ------------ ------------------ -------------•------------ Owner �- <br /> BY - ------------- ----------------------------------- Title __�_ <br /> (I other than owner) <br /> DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY ---- - --- -- - r ---- ---------------------------------------- ------------------- DATE ------ 0 1 = G ----------- <br /> BUILDING-PERMIT ISSUED - -------------------------- -------DATE ---------------------------------_ . ---------- <br /> ADDITIONAL <br /> - -- ---- ---- ------ ----------------------- <br /> ADDITIONALCOMMENT ---- --- ----- .,----- - - ---ti r-----------•----------------- ------------------ --- -----------------------------------------------------•-- <br /> -=7-u------------ > --------- -3------ - ---- --5------------------------------- <br /> ------------------------------------- ---- ------ -- ----- - -------------------------------------------- <br /> ------- - - ---- --------------------------------------------------------------------------------------- -=-- ----------- ----------------------- <br /> FinalInspection bY- ----- •-- - - --------- ---------------------------------•------------------------- -----------------Date ------ ------- <br /> N <br /> ---/N JOAQUIN LOCAL HEALTH DISTRICT <br /> F- H- 9 1-W3 Rev. 5M <br />