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FOR OFFICE USE: 'PLICATION FOR SANITATION PERMIT <br /> � -Permit ermit No. . .....-- <br /> •--•..__._._................. ............... _ (Complete in Tripycate) <br /> _... <br /> d r�' Date Issuedof, <br /> ------------ This Permit Expires 1 Year From Date Issued <br /> �3plicotion is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> escribed. This 7211catinii.�ma;le in comp11 cue with County Ordinance No- 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION Fac/�������-�t Hcw.0-. <AVS r/d AlW)!.. ......CENSUS TRACT ......... . .,....._.._ <br /> Owner's Name/r144A/r,;A._(Jr"11F_1 -��ST�('f.477 ............•........ <br /> ... <br /> Address .liRn! `e�SG`G'� .GSF/yl/Tl A1.i ,.- ... City/� n!7 �/4 <br /> Contractor's Name )SDA •- - .. License .l`�-j���' Phone ?'?-3' <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ",&V,6/y7,f_Q9!- <br /> Number of living units: Number of bedrooms "``__.Garbage Grinder Lot Size <br /> Water Supply: Public System and name .............. _ .......................------- . -------... PrivIte <br /> Character of soil to a depth of 3 feet: Sand)Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam (] <br /> Hardpan❑ Adobe ❑ Fill Material 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: 1No septic tank or seepage pit permitted if public sewer is available within 200 feet,) L� <br /> l� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ....._ ._ _ Liquid Depth <br /> Capacity T <br /> -- - YP _e .............. Material No. Compartments .-. -.--- ......... <br /> Distance to nearest, Well ................... ...__..-Foundation _ .. Prop. Line -------. ._..,.----_ 1� <br /> LEACHING LINE (LJ"' No. of Lines .3 Length of each line 1406P _ Total Length _-_3cc -.- <br /> .... ... . <br /> 'D' Box ' * . Type Filter Material/fofpkC( .. .....Depth Filter Material /F." _ ... .................• <br /> Distance to nearest: We11 . . ..JIJ............. Foundation .._.. ....... Property Line -.. -. <br /> SEEPAGE PIT [ Depth Diameter Numbe• ........... Rock Filled Yes ❑ No Q <br /> WaterTable Depth ............................................._Rock Size ...................... <br /> Distance to nearest: Well ....................Foundation Prop. Line ....__.._..-.--_-. . ti <br /> REPAIR/ADDITION(Prev- Sanitation Permits# <br /> ........................................ Date ............................... ) <br /> Septic Tank (Specify Requirements) _.. ............................. ......... ...... <br /> Disposal Field (5pecify Requirements) , '� "--'-•-'__- <br /> .�x/sr,� s sr....-.........c.............. s...... �ys.r ................ <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 Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signe d^ �p /� _...-.._ Owner <br /> By l�• �J, ✓1. ......................... .. . -.._ _ - Title �I�OPr/3�.F/i? <br /> (If other than rl— <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 8Y — .. DATE ... .- �" 70 •— <br /> "'_.._..--._ ---.....I—-...... . ...................: <br /> BUILDINGPERMIT ISSUED .................................. .....__......_.............,...._..._DATE ......---------............ <br /> 'nDITIONAL COMMENTS ...........................................,............................................................. _ _­.............._................ <br /> .......... <br /> �................................ . _......----.,.._.............------_..•---_.._............ .._.._.-.._...._.._......-._......_....•.•.......-- <br /> Final lnspection.by....._. t1f....� ...:................... ...................... .......... ..................Date �'I' ,'7�......._,.._. .... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-•68 Rev. 5M <br />