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FOR OFFICE USE:' � 3 <br /> - APPLICATION! FOW SANITATION PERMIT <br /> ......... ------------- ----- <br /> (Complete in Triplicatet) Permit No. <br /> ... ..........................-------------- ----------- <br /> < - Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Q ci'7_ VS WIAN v' �Rx1� - 7 r E%l �Gid%110 Rc 7v � - ►j i L y S/Or. <br /> j Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install .the work herein <br /> 4 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> J08 ADDRESS/LOCATION .,� � __-'.r_--7�`�� --110, ----------------CENSUS TRACT . _�g.................... <br /> -- <br /> �'. "C f L- -S� ,�r�� - .......................... <br /> ...................Phone5 -o-4.0 ----------- <br /> Owner's Name <br /> Address <br /> Address ' ................. City <br /> �^ Phone=_Y --�-. <br /> Contractor's Name7Z-x.�blS�/d�_.1."e/aTC..-!/f�/�� ........... - <br /> Installation will serve: Residence [0partment House, i rmmercidl'OTrailer Court 0 <br /> Motel O Other - -------- <br /> Number of living units: ------ Number of bedrooms .. _-_.;Garbage Grif�dern-_, Lot Size -__ - C°`r -- - ------ <br /> r - <br /> L Water Supply: Public System and name -.._'` ----- --------•--------•----- -- - <br /> Private1-� <br /> Character of soil to a depth of 3 feet: Sand. Silt fl Clay ❑ Peat O Sandy Coam ©Clay Loam T-` <br /> Hardpan O Adobe'O Fill Material ----- ---_- If yes,type _ <br /> (PI-ot plan,-showing size;of iot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) Cr�, <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sever is available within 200 feet,) <br /> ,-� <br /> Size - ��-- Liquid Depth __-!f- ----------- <br /> PACKAGE ----_.TREATMENTJ ] SEPTICTANKT4 ----_. (� <br /> 4 Capacity A?0.,(1.-_.- 7y���=-__��9$-'Material-�� � No. Compartments ...................... („ <br /> f i �� <br /> Distance to'�h6aresf'iWell ......... ..............Foundation __-_____.__._ Prop. Line _.__-..-�_____.•--__- <br /> _ o <br /> LEACHING LINE [�No. of Lines)_' '__r_= :''! Length of Bach line_ Ya----------- Tota! Length ................ <br /> D' Box.+ -- Type Filter Materia -4-CA:------ Filter MaterialIf-'e�.....................:........ <br /> 1e <br /> =--j Distance-to-nearest:,Welh�-�� .-- -_—= Foundation .-a._...._-._..____ Property Line <br /> ` - Rock filled Yes 'No <br /> ' SEEPAGE PIT [ J Depth -_-._-_.� -.___ +Diameter ---------------- Number .-.- ----.--__--__..._ ❑ (3 <br /> Water able Depth .�-------- Rock Size <br /> + Distance to nearest: Well ------------------------- --------•----Foundation ----- ----_-_----- Prop. line .......... .......... <br /> r <br /> 5 <br /> REPAIR/ADDITHM 1Prev-. Sanitation Permit# -•�`_:_-.------------- Date-- ---------- ----------- <br /> - <br /> kSeptic Tank.(Specify Requirements) .................... +.r A[ .' r� `",R_�"•�-- _ `,. '_��.�'----�• .. <br /> { <br /> - - <br /> �� . <br /> l ------ - --------- -•---•--- .................. . <br /> + (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the,,work will-be':dene in accordance with San Joaquin \ <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin locaf'Heblth Diitrict:Home owner 6 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 Compensation laws of California." <br /> Signed _ __.� --._ wne - - - <br /> '-------------------- - ....... . .--- r;= 10 <br /> .� <br /> (� + Title . ,4r . '`lr.�/s o✓ ".,_' .-. <br /> By 11�. .cc - ------------ <br /> '_(If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ' 'a -- ---------- ----------- .......................... DATE ....... <br /> BUILDING-PE-RMIT.-ISSUED.-.-r-_—=•.•.f_- - —�-•�-- �..»r=— -- --�-M- �--�------ DATE ._......,............._.................. <br /> ADDITIONAL COMMENTS . `, ^ '1._...... S. `� 5��= :=":.r_7....._ ._. c.. �+�-------- -------•---- ---------.-_------•- <br /> ............. •--.•__-- -- -------------- - -•--- - -- - --__ _«---...... ........... --- .. _ - ---- <br /> --------------------------..- ---_- --•---_--- ..---••-•-•-----_- - --.-. ----- -..--_•----...----•-••-•----••-•--•-•-'-----------------------_.---- ................ ..... <br /> -_ <br /> •--•-•_---• ----_----•_---_-_---•----...... -- - ----------- ------ -.... ..... - - -- ---------------- --- <br /> ---------------------------- _-_--.-._._..-_.._._....._-.-.........---• ( - <br /> Final Inspectio Date ....... J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev, 5M <br />