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;r'JK U171-ICE USE: <br /> ....... ....... APPLICATION F-Oa—S:nITATION PERMIT <br /> ............. ..............I......... ...... (Complete in Triplicate) ...6f. <br /> Permit No. <br /> .........I....... ........ --------- ThIsPermit Expires I Year From Date Issued Date Issued —...'..'7.. . <br /> described. This application is m pe <br /> Application is hereby r-nade, to thi San Joaquin Local Health District for a permit to constructand install the work herein <br /> ode in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIQN <br /> Owner's Name ...... .............CENSUS TRACT ...... <br /> ........... <br /> ...................Phone <br /> Address <br /> ............ city <br /> P, __.... ................ ................... <br /> Contractor's Nome ........ .. Le <br /> ................ ...........................License <br /> # AVL 'Phone17Q5. L7i ,T <br /> Installation will serve: Residence Apartment House 1[] Commercial oTraller Court r] <br /> Motel Ej Other _-,...-........ <br /> Number of living units:'.-,),..- Number of bedrooms _.-3----Garbage Grinder ............ Lot Size ... <br /> ............... <br /> Water Supply; Public System and name ....... <br /> Character of soil to a depth of 3 feet. Sand ............................... .......... ......... ....................................... ......Private <br /> 0 /R Silt 0 Cloy 0 Peat 0 Sandy Loom 0 Clay Loom 0 <br /> Hardpan 0 Adobe 0 Fill Material ........ if yes,type ............... ............ <br /> (Plot plan, showing size of lot,'19cotion of system In relation to wells, buildinis, 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 I ] Size.__. -'I- — _>c / h . <br /> ff-- • ........... Liquid Dept <br /> Capacity A;L -O.... Type q2fl-e-0!� oteriol--- a., Compartments ...... <br /> Distance to nearest: Well 7 <br /> 0 ------_-----Foundation06 <br /> ................. <br /> LEACHING LINE No. of Line's - _t2............. length of each - <br /> line.... p. ..T.. ....... Prop, Line ..45 otal Length 44/ <br /> ............... <br /> 'D' Box Type Filter Material e"X49-4�Depth Filt'er Material ./ ........................ <br /> ..........-,•--•-,... <br /> Distance tolnearest: Well ...._ 4' A ....*....... <br /> , '-- I Foundation Properiy Line ..... ......... <br /> th ------- Numb ....... ................ R ck Filled No <br /> abi ''eOlh . 4\ S-20 <br /> --------- k Size .............. <br /> e <br /> ter <br /> T <br /> ...... .... <br /> Dista <br /> OV or <br /> is to e ............................Foun Ion ........... <br /> ...... Pr P. Line .......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit 0 ...... ...... ------- .................. Date .............. <br /> I ............. ...... <br /> Septic Tank (Specify Requirements) ...... ............a <br /> ­........ -------------------- .............. ........ ....... .......................... <br /> Disposal Field (Specify Requirementsl ._..../.._,..._.._ ............................ <br /> ............................... ---------------­--- ----------- ....................................... .......................................................... <br /> ...... ............................... ------ .......... ....................... ----.----••------•-- <br /> .------...------ ---•-------------- - <br /> .........................................................­­­­----- ........... ----••---•-.... _ ___ _­­............ ................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that tho",work wilf be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local 1`118011111,13istrid. Home owner or Iken- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work'for which this permit is Issued, I shelf not employ any-person In such manner <br /> as to become subiect to Workman's ComPinsation laws of California." <br /> Signed --------------- <br /> ---------------------- Owner <br /> By ........ <br /> .. .......(I.f.-other .................. Jitle .:......... <br /> r than owner) --------------------_ .....-.•----- - ... .... ... .... <br /> FO DEPARTMENT LIST: ONLY <br /> APPLICATION AC BY <br /> ACCEPTED I <br /> ............. ................... <br /> BUILDING PERMIT ISSUED ............... .......... DATE <br /> .............. <br /> ........... ... ......... ....... . --------- <br /> ADDITIONAL COMMENTS ...........DATE'. <br /> 4 <br /> .... ....... ... ....... .................... ......................... <br /> ..........__....... ............ .........,........ <br /> ................I, ...... ........................................... ... .........**"*............. <br /> ---------- ...... ........... .............. ......... ......................... ................................ ....... <br /> ........................................ --------- ...... ........ <br /> - ------- ----- <br /> ­ia1'Ins'p*e'ction'by:_...- ...a�e­ <br /> EH13 2L 1-68 1tev. ................................. ................... ......... to <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ......... <br /> 8/7h 3M <br />