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FOR OFFICE USE: I . <br /> APPLICATION I�FOR SANITATION PERMIT FOR OFFICE USE: <br /> --------------------------------- ---------------------- <br /> (Complete in,Triplicate) Permit <br /> 1. Date Issued.C5.:_'3,/:712 <br /> .......... ..................I ------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to-the San Joaquin Local Health" District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and R I Mons; <br /> JOB ADDRESS/LOCATI ON..... AMW-9- <br /> ...... ---- --- -- .............. ---------- _------ .CENSUS TRACT..............•... .......... <br /> Owner's Name.. h <br /> ... <br /> Address-......./02-07q... nl . __City <br /> ... .........P one. <br /> ..... . <br /> ............... <br /> Contractor's Name_...._....._._... ... <br /> --- ---- ...... ...... .........License Phone- -- <br /> Installation will serve: + Residences Apartment House Ej Commercial n Trailer Court El <br /> Motel ❑ Other....... <br /> I Number of living units:-.. .......Number of bedrooms..,?..1 Garbage Grinder---.........Lot-------Lot.Size-- <br /> 0 ............... <br /> Water Supply: Public System and name. ....... 11 <br /> ............. .......... ------------ -------------------------- --------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ 'Silt E] C,lay E) Peat ❑ Sandy Loam ] Clay Loam <br /> Hardpan Adobe,rFill Mat" <br /> erial . .... _...If yes, type-_---------------------------- <br /> [Plot plan, showing size of lot, 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 /> Size <br /> Capacity./_G_�00----- Tyl ........ <br /> 'PA --- Material_ .........;No. Compartments---...:,4 ---------_ <br /> PACKAGE TREATMENT SEPTIC TANK .5/ / <br /> .-Liquid Depth.' <br /> Distance to nearest: Well_...` A .................Foundation...16... .......I ..Prop. Line-.--.S.. -------- <br /> ot If 0 do 6 <br /> LEACHING LINE No. of.Lines... ---------.-.-.--.Len h of each line, IVO_VO_9�0-------Total Length ...... ........ <br /> *0 0D' Box...600".-Type Filter Material Depth Filter Material_ _141?--------------------:.......... ...... <br /> Distance to nearest: Z�_ Foundation.. 0.* 0 <br /> - 10 ..-._-_--:_I i , . .............Property Line....5 5. . ............... <br /> SEEPAGE PIT Depth-A.C! -3.. j <br /> .Diameter- ........ ..Number.._. ---- <br /> �# 0 Rock Filled Yes;K* No <br /> Water table Depth.-----AD-6_...... -----------------_---------Rock <br /> Distance to nearest: well.__.__,�6- 9 <br /> ............... Foundation---- .. ....Prop. Line..s ..)%0* <br /> - - U-... <br /> REPAIR/ADDITION {Prey. Sanitation Permit#--------------------....... <br /> ... . ....... . ..........Date -------:.......... .. .... <br /> Septic Tank (Specify Requirements( ........... ._------------------- -- <br /> --------------------------------------------------------- --------- ----------------- ...................... <br /> Disposal Field (Specify Requirements)... ­........I------ <br /> .. .......... --------- ....... <br /> .......................... -----------------1----------------- -------------­-------- ....... <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 the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Ru'les and. Regulations of t9e Son Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of work for which this, permit is issued, I shall net employ any person in such manner as <br /> to become sub' to to Work Compensation laws of California." <br /> .n s <br /> Signed.------. ---- . . . c,....... <br /> 7------ --- ----- ---------Owner <br /> By. ............ <br /> ­ - <br /> ---- ----------------- Ja/;00------ --- <br /> �---­ ... ---i(-. .,�...Till. ------------ . ....................... <br /> (If other than owner) <br /> E EPAI ONLY <br /> fft PARTMENT USE <br /> APPLICATION ACCEPTED B <br /> --- ----- .-------•------- ---- -- DAT E,....7'/ <br /> DIVISION OF LAND NUMBER.'-.......... DATE.----------.------- ...... <br /> .......... ....................­_­.............. ............................. <br /> ADDITIONAL COMMENTS ............... <br /> --------------- <br /> ............... -------------- ------------------------ ... ------------- ---------- <br /> ---------­--- ------- ..... ......... ......I------------- ....... ­-------------------_--------------------I.......... ------- <br /> ----------- ..... ... ------1�..........i-----------------­-------- -------------------------------------------- ­ ---------------------_ <br /> --------- ------ ------ -- --- - ------ -------------------------------­----------­- ---------------------_ <br /> Final Inspection by:_.. 11 -------------------- <br /> ------ - Date------------------------------------------- --- ...... <br /> ----------------------- <br /> EH 13 24 <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M <br /> <ZED <br />