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FOR OFFICE USE. ; <br /> APPLICATION ICOR SANITATION PERMIT <br /> ........ .........................--.............. <br /> . <br /> Permit <br /> (Complete In Triplicate) <br /> No. ....................: <br /> . This Permit Expires t Year From Date Issued Date issued . -........... <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in complia ce with County Ordinance No. 549 and existing Rules and Regulations- <br /> . <br /> egulations: <br /> 1 <br /> r . <br /> JOB ADDRESS/LOCATIO /D.k.�__.. .. .................•-•-.....CENSUS TRACT .......................... <br /> Owner's Name ...... Y ................................. ............Phone ....------ <br /> 3 <br /> �- Y67 <br /> Address __._.-.---••-.7�5., ..................City ..- <br /> -----------------•- <br /> Cantractor's Name ......... License #4)i �: 1.3..--- Phone "`_ -------- <br /> Installation will serve: ResidenceApartment house E] Commercial pTraller Court <br /> /K <br /> Motel ❑Other !7a Z T> <br /> Number of living units:--- ---- Number of bedrooms ...:,/_._...Garbage Grinder ............ Lot Size --••...................... ..__..--.--. <br /> Water Supply: Public System and name ------•• -•-•--a.----------------_------------------------....4....---._1........I...---•-........ :Private <br /> Character of soil to a depth of S feet: -Sand❑ Silt El ; Gay ❑' Peat Sandy tocm �] Clay loam ❑ <br /> r� <br /> _ Hardpan Aclobe)o Fill Material ............if yes,type............... ............ <br /> (Plot plan, showing size of lot, location o system_In.relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: IN* septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK S' e.--., � _� ..........:............... Liquid. Depth .S _...........__-- <br /> Capacity l ?Q 'D._.. Type _- --- .-•.'... ..Materlal._` ..G1:: No. Compartments -3................ <br /> Distance to nearest. Well �f'` �~ <br /> �!! ::.----J.......Foundation ._.li .�.�� ..__ Prop. Line _ ..-----_.-- O <br /> LEACHING LINE ( No. of Lines .----- ._........., Length o�ojin e------.•- - _ TotalLength ----- - --•............. 09'D' Box ._.._��Type Fitter Materia) _ ..Depth Filter Material .-. P.._�.................•---___- <br /> Distance to nearest: Well _`. ...... Foundation ..... ...... Property Line 0-r ' -------- <br /> SEEPAGE PIT • <br /> th -•De r <br /> p ----------------- Diameter ---17;_r{ <br /> ... Number -............�............ Rock Filled Yes� No <br /> Water Table Depth .........................i--...._...---.. Rock Size �• �i j� ..-•-•- <br /> Distance to nearest: Well ...... ----_------------------Foundation ....ld!(:I`-..... Prop. tine .... ......... <br /> REPAIR/ADDITION{Prey. Sanitation Permit#-------------_ ---_--------------_--- Date _.........------ <br /> •------...........) <br /> Septic Tank ISpecify Requirements} ................. <br /> Disposal Field (Specify Requirements) ----------------- •--------•-------- .......... ................... <br /> ............................----•-------------------- <br /> ----•--•-------------- ........---- <br /> �-- .,by <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 Son_Joaquin.Loeall.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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --..--------••--------- <br /> By Owner <br /> .. ._ __.................................. Title ---- -- ... ' <br /> ( of than owner) <br /> FOR DEPARTMENY LJSE ONLY <br /> APPLICATION ACCEPTED BY ---------------- •-------------•------------•-----------------.._.. --- •------- DATE <br /> BUILDING PERMIT ISSUED �i-_.-- DATE ------------------ <br /> ADDITIONAL COMMENTS . . �`t - - <br /> ------------••----------------••-• -------------------------•------...-..__.. ---- - - --- --.._.. <br /> -----------------•-._-_.-.------------------------------------_....-_....-----...-------------------------•----------•- <br /> Final Inspection by: ....- , ----------- .... ...........Date _.9_'� ".f_?Q.._._.. <br /> EH <br /> 13 2 68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 6/7h 3M <br />