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FOR.OFFICE USE: <br /> r APPLICATION FOR SA ITATION PERMIT <br /> z= . .. <br /> t Q Permit Na. _7.4.... g <br /> (Complete in�Triplicate) <br /> -------- This Permit Expires 1; Year From Date Issued Date Issued .7-/ :.7 <br /> Application is hereby made to the tan Joaquin Local Health District for a permit to construct and install the work herein <br /> l described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> i <br /> JOB ADDR1wS5/LOCA ON ,..... ------ ------------------------•---.-•-----...-..._CENSUS TRACT .•.. ......... <br /> Owner's Name ...... ��....................r--------------. .... Phone 5�•�� 770-S� <br /> Address _......._.- C�..7...7..- - ........ -- .... City ......................... <br /> - <br /> ..._ <br /> Contractor's Name ............. ..... .....•�._......__-- ---- ----� .........--------License #. `t 'f __._.-- Phone .T.Q._�.: ... <br /> (< k.. <br /> Installation will serve: Residence Apartment HouV'Commercial ❑Trailer Court Elk - <br /> Motel <br /> ]' <br /> M tel Other 4i <br /> / o-. __ ---------- ----�=-- ----Number of living units:.....L,.___ Number.. of bedrooms=Garbage Grinder., .'...`7Cot Size ....._�_v_ .��5............. <br /> Water Supply: Public System and name.._..--.--_ ' �:�,•�..___._____•_-!_------...... --- --4 ..1'...-...• ................. .Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑)Pegt[] Sandy L a ❑ Clay Loam ❑ <br /> M <br /> Hart'� • <br /> t dpan,❑ A� dohe�.�ill aterial _..._._._... If yes,typ ----.._.._..•---. ....... <br /> i (Plot plan, showing size of lot, location of. system in relation to wells, buildings, etc. must b'i%o ed on reverse .side.) <br /> 1 <br /> ,NEW INSTALLATION. (No septic tank for seepage pit permitted if public sewer is available within 200 feet,) <br /> _ ACKAGE TREATMENT [ ] SEPTI TANK ] Sia .............................------ - ---- Liquid Depth _..-.._.......--_.......... <br /> t Capacity ...-....._11._.__...- Type .................... Material......_......__._.�'"'1No. Compartments ................... <br /> .__ <br /> .----Foundation ------------------f... Prop Lihe . <br /> Distance to nearest: Well '•-Len Length of each line.-.... ... � ................ <br /> •- • . <br /> LEACHING LINE [ J No. of Lines ...�.... ... . ....... . g - <br /> .... Total Length <br /> rj <br /> 'D' Box ........... Type Filter Material . ................ Depth Filter Material! x n.........I....._..... <br /> Distance to,neatest: Well ................:....... Foundation ..... __._..... ........ t l- <br /> ance Property Line .:.................:.... <br /> Dept <br />' 'SEEPAGE PIT [ I Wateh Table Depth .-Diameter--•••••-__-•.-•-- B�IvmbeRock Sze,�_i��__�"a-Rock,Filled Yes ❑ No (] <br /> .i <br /> Distance to nearest. Well ___________________________.............Foundation ............._...... l!Ptrop. L no ................... <br /> REPAIR/ADDITION IPrev. Sanitation Permit# . ........ ............................. Date . ..................... <br /> r � __ <br /> s' Septic Tank (Specify Requirements) <br /> - <br /> E Disposal Field (Specify Requirements) ____ Z". <br /> ,�-..-� .. f----- -•----. <br /> y L <br /> y , <br /> .. - .�f ._.. a .•• .._..-•---- ........ ........................ <br /> -----•---------------------------------- ----------------------------------...............•......................:-._.................. <br /> . <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby terrify that I have prepared this application and that the work will be done in accordnce with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District) Homs owner or Iicen- <br /> sed agents signature certifies the follow1n4g: <br /> "I certify that in the performance of the woe-k-f6r,which=this-p•ermit,it-issued;I halal not employ any person in such manner' <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed <br /> j _. Owner <br /> By I t. .: . Title <br /> J---- <br /> (if oth t an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED -� <br /> I' - <br /> I' CC TED i3Y ..•--- =--=-----------••-•---...------- --------------••--•----...•--..:....----------------__.'-'-:--�'DE1TE-- - ---- -- <br /> BUILDING PERMIT ISSUED I s ... .................... <br /> .......DATE <br /> ADDITIONAL COMMENTS ' t r ► <br /> ,._..... .........................................•••----------------.-.. -.- -•-•----:.-------------------------- <br /> •-•............t I 1 t , <br /> �, « ............................ . . <br /> .......... ............. ................ / . ...: :.... , __...._� ............................................................ <br /> i _ <br /> Final Inspection by <br /> ....,_ - .................................... ......Date .... ..._... ----....-- <br /> v,„,_ SAN .JOAQUIN JLOCAL' HEALTH DISTRICT <br /> E. H.13 24 1.'b8 R.v- 5M C' C� J 7179 3 u <br />