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'FOR OFFICE USE: <br /> ..........I................. .......... ............. APPLICATION .FOR SANITATION PERMIT <br /> Permit No. <br /> .11 lComplete In Triplicate) <br /> ..........I...... ...................... <br /> Date Issued I;2-11.21.7y" <br /> .......... ...:.............IM.... This Permit Expires I Your From Date Issued <br /> Application is hereby mode to the Son Joaquin Local Health District for a permit <br /> mit to consfrud and Install the work herein <br /> described. This application'lls made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION:, <br /> .......... .............I...........CENSUS TRACT ................. <br /> Owner's Name ....R'17- ........................ ..............:................Phone <br /> ............ 21... <br /> 0-11 ----------IC--------------- ....... .................Phone ... <br /> Address .......................... XA"J!��......7 ............... ....... ......................city ....................... ............................. <br /> Contractor's Name c.........---..License # ........................ Phone VC6=121.E477..; <br /> Installation will serve.. Residence 0 Apartment Hous e 0 Commercial OTraller Court 0 <br /> Motel 0 Other............................................. <br /> I Lot Size .................. <br /> ............ .7 <br /> Number of living units: Number of bedrooms ...:3....,Garbage Grinder . .. ... <br /> 10 <br /> Water Supply: Public Syst4 and name ---------------- ---------- ..................... .................................... ....................private 0 <br /> Character of soil to a :10 n <br /> depth f 3 feet: Sand 0 Slit 0 pay [3 Peat 0 Sandy Loam 0 Gay Loom <br /> Hardpan 0 Adobe 0 Fill M6terlal ............ If yes,type................ ............ <br /> Ir <br /> (Plot plan, showing size olot, location of system in relation to wells, buildings, 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 TANKSize........ .. <br /> ............... Liquid Depth ............ ........... <br /> Cal M- city /2-0 .. .. Type Cca-ixA 4!9�Material...................... No. Compartments ....2............. <br /> Distance.to nearest. Well ...-VA........................Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE N of Lines ......................... Length of each line..................:......... Total Length ............. ...... <br /> Box ...... Type Filter Material ....................Depth filter Material ..2-.................................... <br /> Distance to nearest: Well ------------------------ Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT Deoffi -------------------- Diameter ................. Number ............. ......... Rock Filled Yes ,[] No <br /> 13 <br /> Wdter Table Depth .... ....................................Rock Size ............. .................. <br /> Distance to nearest: Well ---------------------*..................Foundation .................... Prop. Line ................... <br /> REPAIR/ADDITION(Prev. Scinitation Permit# ............... ...........................- Date ...6..........!.................. <br /> Septic Tank (Specify Requirements)........ ...... .................... .......................... ................. <br /> Disposal �Fielcl fSpecify Requirements) .-LIpp <br /> 5 ........ ......... ... .0-mzsA - <br /> .... y.- . ............ <br /> --e. ...................... <br /> ......... . <br /> ---------------------------------------------I1=-------I--------------------------- --------------11-•- - ... ....................... ................ ...................... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I havil prepared this application and that the work will be don:* in accordance with San Joaquin <br /> County Ordinances, State t6ws, and Rules and Regulations of the Son Joaquin Local Health,,District. Home owner or licen- <br /> zed agents signature certifies the following: <br /> "I terrify 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 Wo.rkman's Compensation laws of.California." <br /> Signed ......i!--AA--111 --------------- Owner <br /> By -------------------- TIC116-N-1---Qn.�.............--...... --------------------- Yitle ............... ....... ........... <br /> (If other than i wrier) <br /> FOR DWARTMIENT USE ONLY <br /> APPLICATION ACCEPTED dy' ----- ...... -.t,.---�---------------------------------------------- DATE ---------- <br /> BUILDING PERMIT ISSUEDII;------------- .................................. ........................................... ------------DATE .... <br /> ADDITIONAL COMMENTS --------------------------------• -• ----­r............. ....... ---------------------------- <br /> ----------------------------------------- --- -------- --------------I-----------------------I------------------------------*----------- ------ ........................................I......... <br /> --------------------------------------- --------------- <br /> ------------------------------------------------------------------- ...... ---------------------------------------------- <br /> --------------- --- ..... . ............ <br /> L�............ ................ ----------------------------Date ../4 ....... <br /> --------------- -------------------------------------- <br /> Final Inspection 44 .. -;/...... <br /> EH 13 2h 1-68 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />