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FOR OFFICE USE: <br /> APPLICATION FOR SAWATION PERM <br /> ................................................. Na:tComplete in Tripfic�ttte) Permit .................. <br /> %*Moe ------•-----. --•---- ------------------- <br /> Dote Issued <br /> --_..__._-...................................... This PermitlExpires I Year From Datelssued <br /> Application is hereby made to the San Joaquii Local.Health District-for a permit to construct and install the work herein <br /> described.This application is made in compliance County Or <br /> y Ordinance No','549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIOI� -----------------------—------ ---------------------CENSUS TRACT ......... ........... <br /> Owner*s --------------------------------------------Phone------------------------------------ <br /> Address ...... ------ - -- ----------------------�7 U City ------------------I----------------- <br /> K 7 ......... <br /> Contractor's Name........... ------ License# Phone .............................. <br /> Residence partment Hou <br /> Installation will serv6-. em so E] Commercial C]Tro!10 Court 0 <br /> Motel M Other............................................ <br /> Number of living units:_ --- Number of bedrooms.__9.-"',Garbage Grinder ------- Lot;Size <br /> Water Supply. Public System and name --------------------_----...............................---------------------------•-------­---------------Private <br /> Character of sail to a depth of 3 feet.- Sand 0 Silt 0 Clay 0 Peat El Sandy Loom 0 Clay Loom E' <br /> Hardpdn 0 , Adobe 0 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 13 available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK T j Size................................................ Liquid Depth -----------.-------------- <br /> Capacity <br /> ------------------------ <br /> Capacity ------------------- Type ..----.------------- Material......__.----------_-- No. Compartments ............ <br /> Distance to nearest, Well -..............._--................Foundation..............-------- Prop, Line-.__.....__---_------- <br /> LEACHING LINE No. of Lines -------------_-------- Length of each line_.__._._._..._____.._._--:::--Total Length ............................ <br /> V Box Type Fil4r Material ..........--------Depth Filter Material --------------------- --_---------------_ <br /> Distance to nearest: Weil ------------------------ Foundation -------------- Property Line. ....----•°-----._....-.. <br /> SEEPAGE <br /> ..-------------------- <br /> SEEPAGE PIT Depth .................... Diameter -------------... Number --------------------------- Rock Filled Yes 0 No C] <br /> WartaT Table Depth __---------------------------------------Rock Size---------------------- <br /> Distance to nearest:Well .............................1. 7:.Fautidation ------r-----------.. Prop. Line................. <br /> REPAIR/ADDITION lPrev. Sanitation Permit# ......................................:­_Date.,___j--------------------------- <br /> Septic Tank (Specify Requirements) ............ ..... ......... ---------------------------------------1............ <br /> ---- ---- SF <br /> Disposal Field (Specify Req - ------- .. .Zk... ........ POc........ <br /> J -------- <br /> ........... .............................................------- -------------- <br /> - <br /> ------- ----------- ------- ------------------------------------- <br /> I (Draw existing.and required addition on ��Wl 6 i44 <br /> I hereby certify that I have prepared this application and that tfiii'work-wIIV*bv-don& 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 been subject to Workman's Compensation laws of Califomto." <br /> Signed ........... .1--- - - ------------ --------------------------Own" <br /> 9 <br /> By --------------........... ....................................._ � Title <br /> lif other than own r) <br /> FOR DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED BY --------- -------------------------------------------------------- DATE One7��Y�------------------ <br /> BUILDINGPERMIT ISSUED------------------•-----•---------•--------'.---------- ...................._.._......_..........._..._.DATE. ........ --••-----------I......_..... <br /> ADDITIONALCOMMENTS............---------- --------- -------........I--------­­----------------------------------- ....................................... <br /> ......... -------------------------------------------------------------------------------------------------------------.........I....................................I—- <br /> -------------------------- <br /> ------------------- --------------- ------------------------------ ------------------- ­-----------­-------­----------- <br /> y- ...................................................... ­------Date <br /> ---1--- -- ----- ol___ :i?*------------ (Y- ---------- <br /> -- --------- ------------------------------------------------------------------ -0. <br /> Final inspection b ----------- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --f.H. 9 1268 Rev.5Ak' <br /> Namw <br />