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rVIK UFFICE USE: <br /> ------------ <br /> APPLICATION FOR SANITATION PERMIT <br /> . ...................................................... <br /> .. -------... ...... . ICOMPIete In Tdplicate) Permit No. 2Z1............ <br /> ......................................................... This Perm It Expires I Your From Dow issued Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and Install the Work herein <br /> described. This application is mode in compliance with County Or '.ante <br /> 549 and existing Ruler. and Regulations: <br /> JOB ADDRESS/LOCATION <br /> - <br /> 7.....................CENSUS �TRACT ...................... <br /> Owner's Name <br /> ........................................................ ..•.........Ph no <br /> Address. ...... ...... <br /> 4111.�--------------- .......I......... ............. City ................. ......... <br /> ........... <br /> Contractor's Name ............. <br /> . . ...... ...........License # 'e7 <br /> P <br /> m-�tH—ef .. Phone .�-,?/;P//-,. ';7 <br /> Installation will serve: Resiaenoe artrr;im 14o <br /> $80 Commercial OTrailer Court 0 <br /> Motel 0 Other....... <br /> Lot <br /> Number of living units:_-__....__ umber of bed S, <br /> foorns ----- ..�age�,Grinder ........ Size-Gorboo, i? <br /> Water Supply: Public System and name ) ........!......... ...... <br /> .... <br /> ...... Private 0 <br /> Character of soil to a depth of 3 feet: Sand C] Silt C3 clay 0 peat[] _"<.............................. <br /> S&'ndy Loom 0 Clay Loam [51- <br /> IN.-* <br /> Hardpan El Adobe f:] Fill M6teriol...... If yet,type......I....... .........— <br /> (Plot pion, showing size of lot, location of system In relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic r tank or seepage pit permitted if public sewer is available within 200 feetJ <br /> PACKAGE TREATMENT f J SEPTIC TANK Size.......... ............. <br /> Capacity ........................ Liquid Depth ...-----•--... <br /> ............ <br /> ------- --- Type -------- ...... Material________________f ....... . No. Compartments .......I.............. <br /> Distance to nearest.� Well -------- <br /> ...... ..........Foundation ......... Prop. Line ........................ <br /> LEACHING LINE No. of Lines .............. Length of each line <br /> .41 ------A_0.f............ ,TotaI,'_Ler!qth .120.................. <br /> V Box ....... ....,Jype Filter Material ...............Depth Filter Material. .........11......................... <br /> .......... <br /> Distance to I Nearest: Well ............. --------- Foundation ................... Property Line ........................ <br /> SEEPAGE PIT �r Depth 'Diameter 52._r__r_- <br /> ----- Number ¢ 8 No 0 <br /> Rock Filled Y s <br /> Water Table Depth --------------------- -- ------------ ._Rock Size ......./.. . ......... <br /> Distance to nearest: Well ------:_....... -_.Foundation Prop. Line <br /> . ............... ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit*# Date t1117,//......... <br /> Septic Tank (Specify Requirements) ....... ...... ---------_..................I........... <br /> I .................. <br /> ----------- --- ----------------------- *t._._: <br /> .Disposal Field (Specify Requirements) ............ ....... <br /> I ---------- ---------- ----- . ................................ ....... <br /> ------------------­---------------------------------_-, I <br /> . i---­---­------------------------------------------- <br /> ------------- -----------------• - I------------11--------- ---------------- ------------------- ---------------------- .......................... <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 Son Jac.quin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son '40'oquLi-njqca[-Hqplth.,Districi.. <br /> sed agents signature certifies the following: <br /> " -Horne-owner or 1111cen. <br /> "I certify 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 hoc0 me subject to Workman's Compensation laws of California." <br /> Signed .... <br /> ---- -- -- --- ---- - --- ---------- ------- ...... -------- Owner <br /> By .... ...... -- ---- ------ ---- ---- -- <br /> --- ---- - ------------ Title ------------------ <br /> -- <br /> i/7ot er on/w e ------------ <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> -------- ......--:............. ......... ------------ ---------- ......... <br /> BUILDING PERMIT ISSUED .... DATE ....... <br /> Fr7 <br /> ------- DATE <br /> )ME� . ... --- ------------- - ------- ...... . <br /> ADDITION,AL COM 4is ZI_4� <br /> ------- ----- ------------- <br /> V A.- ... . ....... . . A——---------- ---------­---L ...... <br /> ---------- ----------­---------- ------------- I I �:�.................................... ----------- <br /> - ---------------------- ------------------_........I........... <br /> ---------------------------- --- <br /> . . ..... .-.-.-.-.-.-.-.-.--.-------L------- <br /> - . ... ---------- . <br /> ...... <br /> Final Inspection by: ----- ............ ..---........ . ..Y.._..,. Date ...EH 13 .2h 1-68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT ... <br /> ----/-- ---------;--------------- <br /> - <br /> 4 3M <br />