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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No . 7 S7- <br /> ...................................... . ..................... <br /> (Complete In Triplicate) <br /> Date Issued ..././I. - 75......... .......... ......... This Porm'Itip esI Year From Date Issued <br /> Application is hereby made tothe Son Joaquin Loco[ Health District for a permit' to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance NO. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .. ../-.-.7..`-1A-------.. ....................CENSUS TRACT ..............—........ <br /> Owner's Name ------- <br /> ...�. .....................:...............:Phone ......... ........—.......... <br /> ------ ...... City ............ ...... ------------- <br /> Address ....... ......Cl ...... ............... <br /> ,60 Phone <br /> Contractor's Name ...... ------------- - -- -----7� -C'. .._--_........License # <br /> Installation will serve: Residence 0 Apartment House 0 Commercial{]Trailer Court: C] <br /> Motel El Other ..............................7"" -...... <br /> Number of living units-__...(----- Number of bedrooms ..;,}_.....Garbage Grinder Lot Size lmx Z9 ep ....... <br /> 40-N. <br /> Water Supply. Public System-and name ............... .................................................................. ..........................Private <br /> Character of soil to a depth of 3 feet. Sand 0 Silt 0 Clay 0 Peat[] Sandy Loam 0' Clay Loom Xk, <br /> Hardpan 0 Adobe 0 Fill Waterial ............ If yes,type ............... ............ <br /> )Plat plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.)—J <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT SEPTIC TANK Size..........................4......._. ""..:_ Liquid Depth .......................... <br /> Capacity ------ ------------- Type ----—...... ...... Material------------- No. Compartments .... ................- <br /> Distance to nearest. Well ------------------------•-----....:.Foundation ---_......:-•-----•--- Prop. Line ............I........ <br /> LEACHING LINE No. of Lines _.--_------------------ Length of each line-....---------- ............ Total Length ............................ <br /> V Box ............ Type Filter Material ..Depth filter' Material ........ ................ ........ ......... <br /> Distance to nearest. Well ........................ foundation ......... ........ Property Line ....... ........... . <br /> SEEPAGE PIT Depth Diameter ................ Number .-...I_;--_-------------- Rock Filled Yes q No' 0� <br /> Water Table Depth�.......................... ....................Rock Size <br /> ./-.. :.. ................ <br /> Distance to nearest: Well ..................................... Foundation -_------------._ Prop. Line ........... ......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --_----------- ...............—.... Date ........ ...................I <br /> Septic Tank (Specify Requirements) ....... ................. .............................................................................................. <br /> Disposal Field (Specify Requirements) -_-----_--------------........ ..............................I------- .................._....------•-•------...._......------•- <br /> -----------I....... ................................................. ..................I................................. ........................................... ....................... <br /> - ------------------------------------ .............m-------------------­---- -------------I--------- "------""-"----"-"-•----•. ............. ....................................... ....... <br /> (Draw existing and required addition on reverse side) <br /> 1 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 ton Joaquin Local Hisalth,01strict. 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, Vshall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.." <br /> Signed --------- ................... Owner <br /> BY ------------0'r R ---- ------------- litle _ ------- ................ <br /> -------------- ---- -------- ...... .............................. <br /> • <br /> (if other than owner) <br /> FOR JI)EPARTMENY USE ONLY <br /> APPLICATION ACCEPTED BY .... ...... ........ ........... --- - <br /> .... ------- -----­------------ -------- DATE ....... --- -. <br /> --- ---- ............... <br /> BUILDING PERMIT ISSUED _.---------- .'DATE ....... <br /> --­- - <br /> . ..... ----- ------ - -- <br /> ADDITIONAL COMMENTS ----------------------------------------------------- ------­.... <br /> ------------------------------------------ ................................_............ <br /> -------------------------------------------------- -------- -------­­------------ ---- ------------- ...................................................--1-1..................... <br /> -.:::----•--1-.--••...------------------------------ - ------------- -­ -------------------------------------------- ------ .......... .........................­­­.................... <br /> ... ............................. ­ ­- ----------------------------------------- ---------------- ....... - -- - - --------..._.:.:.__:_:h_- <br /> Final Inspection by- -------------------- .... ................. ........................Date _w _ <br /> --- - ---------------- <br /> Eli 13 24 1-68 Rev. 5M SAN LAQVIN LOCAL HEALTH DISTRICT 8/74 3M <br />