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APPLICATION FOR SANITATION PER,, T <br /> ............. ....................... ...... n (Complete in Triplicate) Permit,No. ....7.....6.- 1V7 <br /> ........... ..................... <br /> 7L <br /> .. <br /> --------- ------------------------- -------- This Permit Expires I <br /> Year From Date Issued <br /> coo[PIed ........... . <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 opplicoti6'n is mode in compliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC 0 . . . ...... ...... ..... .............. <br /> 0 . . ... <br /> .......CENSUS TRACT .......................... <br /> Owner's Nome ------------- ---------- <br /> Phone ......... ............ ...... <br /> Address <br /> --­---------- city ............ <br /> Contractor's Nome ........._-Aicense # dIff <br /> Phone ...... ............... <br /> Installation will serve: 11. Residence Apartment House 0 Commercial (3Traller Court 0 <br /> Motel El Other .... ...... ---------------------- <br /> Number of living units_:_. ------ Number of bedrooms ....._Garbo ge Grinder ---------— ..... . <br /> Lot Size ...... <br /> ............. .. <br /> Water Supply. Public Syst;'m and name ......... --------------------------------- .......__...................... ...........Private <br /> Character of soil to a depth of 3 feet. Sand 0 Silt❑ Clay 0 Peat C1 Sandy Loom Z"Clay Loom E) <br /> !I <br /> Hardpan f-) Adobe [:) Fill Mittericil ............ If yes,type .—........... ............ <br /> (Plot plan, showing size.i�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 /> PACKAGE TREATMENT [!j SEPTIC TANK[ Size...-• ..... .. Liquid Dept .... <br /> . Ld h .................. <br /> Capacity ----------------__ Type -------_----------- Material...... --------- No. 'Compartments --_-------- ........01 <br /> Distance to nearest. Well -------•------------------- - ......Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE No. of Lines ------------------------ Length of each line ......... ..............I... Total <br /> Length ............ ... . <br /> 'D.' Box ---------_ Type Filter Material .....__.............Depth Filter Material .......................... ................. <br /> Distance to nearest: Well ................. ...... Foundation ......... Property Line .................... <br /> SEEPAGE PITdepth ...----------------- Diameter ---------_----- Number ------------ ................ Rock Filled Yes ❑ No <br /> Water -Table Depth -----------------_----- -------- ............ Rock Size ._._.....--••.................... <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ................ <br /> .......................................... Date .....................1—.........I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# <br /> SepticTank (Specify Requirements) ........................­.................... ..........I.............................................................................. <br /> Disposal Field (Specify Requirements) ....4-tqz4/.,4_4�� <br /> �- 7 ------_-------- <br /> ----------- ---------------------------------------I------------------­I............... <br /> . ........ ---------- ------------------------------ ------------------- --- ----------------------------.......I--•--- .................... ................................................ <br /> (Draw existing and required addition on reverse side) <br /> I :hereby certify that .1 have prepared this application and that the work will be done In accordance with Sain Joaquin <br /> ' Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home <br /> County Ordinances, StateiI� 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, I shall not employ any person In such manner <br /> as to become subject to �orkman's Compensation laws of California." <br /> Signed ................. -------------- -------------------------------- Owner <br /> B F ,I �` <br /> ------------ <br /> jo <br /> - ------ Title .. .............. <br /> (If other than" .ownerl <br /> AOR DIE �Kl ��Y <br /> K PARTMeNT USE ONLY <br /> APPLICATION ACCEPTED i�iIy .. .... ....... . . <br /> . ...... ......... <br /> -------------------- DATE <br /> BUILDING PERMIT ISSUED ......... <br /> ...... ------- ------- ----------------- -------------------- ......DATE ............................ ........... <br /> ADDITIONALCOMMENTS----- ------------------- -------- ------------------------------------- ------------- --------------------------- --- ...... -------- ....... ..... .. ---------------------- <br /> --------------- ------------------- ------------ .......... ------- ------ .......... ......... ...... ........ <br /> ------------ --- ---------------- .......................... - ------ ----------------- -------------­--- ------------ <br /> .......... <br /> Final Inspection by. ---------- �00o:�� <br /> W Ito- ----- -------------------------- - -----------­---------- ---Date <br /> ER 13 2h 1-68 ltev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 8/7h 3M <br />