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FOR OFFICE USE; APPLICATION FOR SANITATION PERMIT' <br /> ...................................... Permit No.W�7_47/ <br /> {Complete in Triplicate) `/ <br /> %. I Date Issued <br /> ................I...... .......................... <iwli Permit Expires.1 Year.From 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ........................................CENSUS TTRACT ................... <br /> Owner's Name :!77! Phone <br /> ......................... ......... <br /> 4­ <br /> Address .................. y ............................... <br /> ......... Cit <br /> ek <br /> A Phone Y"....7%27. <br /> Contractor's Name .................. .. ------ ..........S.. ................Licens # <br /> Installation will serve: Residence XApartment House f] Commercial {]Trailer Court U� <br /> Motel F-1 Other __................................. <br /> Number of living units:.... ...... Number of bedrooms _3......Garbage Grinder Lot Sizel /.S_o--------------- <br /> ... <br /> Water Supply: Public System and name ------------------------------------------------------------I.... .. ........ ..........Private <br /> Character of soil to a depth of 3 feet:--Sand 0—Silt 0—Cld%/'[]"Peat[:0 Sandy l_oamo,� Clay Loam <br /> Hardpan E] Adobe Fill Material If yes,type ...................... <br /> )Plot plan, showing Size of lot, location of system in relation to wells, buildings, etc. must Ise placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepagiI;pItpermitted if public sis available within 200 feet,) <br /> �iewer Depth .......................... <br /> Liquid <br /> PACKAGE TREATMENT, SEPTIC TANKt Size ............................................ <br /> Capacity --_--------------- Type ----------- ........ Material... ------------ No. Compartments .............. <br /> Distance to nearest.. Well ------- ............................Foundation ..-............. ..... Prop. Line .......................11; <br /> LEACHING LINE .. <br /> No. of Lines .... .................. Length of each line_!... ........ ......... Total Length ...... ..................... <br /> .'D' Box ------------ Type Filter Material ....................Depth Filter Materiall .......................... ................. <br /> 1 1. . 0 <br /> f <br /> Distance to nearest- Well --------- Foundation ........................ Property Line .............. ........ <br /> SEEPAGE PIT Depth .................... Diameter ................ lNuAerl_--..--.___._j-._..._-_.--.. Rock Filled Yes 0 No RE <br /> Water Table Depth ................. ......*........ ..... k cick Size t ........ <br /> Distance to nearest. Well ----------.:•-------__I—A...t...Foundation 4-.._......... ... Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .............N.91 Dalte ......... <br /> Septic Tank (Specify Requirements) ....T!n.... ...... ............. ................. .........­__...-----...-----•------Disposal Field (Specify Requirements) .-t-1 es*w- ------- _1.................. ....................... <br /> .01 M. , . I <br /> ................. ---------------- ---------------- - ---- ------ -- ­­- ------- ----------------­ ..--- ••-•--• <br /> .......................... I-....... ................................------•-- ---- 1 ....IJ---------- ........ -------- ------.------------------•-------..._.... <br /> (Draw <br /> -------------­-------1-1...........­ <br /> (Draw existing and required addition oKreverse 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, Siate"',LaG",k`c;nd Rules and Regulatibrisof4the Saw.lo quin Local Health District. Home owner or licen- <br /> sed agents signature c6tifie's"the f6ilowing: V 1 1 <br /> "I certify that in the pleirformance�df�the work for which this-t pe;;;m4i 'is"�,111 sue.4, 11,_shall not emplo any person in such manner <br /> as to become subject to Workman's Compensation llaws,oftCtilifo.rnia.191 Y, <br /> Signed ........................I ��� .......... C <br /> .......... ---- ------- -- ----- - ................. I <br /> I <br /> Title, ............ ......... ...................... <br /> By ........... ..... . ...... .................................... . <br /> 41if�oithe n owner) <br /> 4 FOR_qEYA?TMENT USE ONLY <br /> APPLICATION ................ ---- <br /> ACCEPTED.BY...... !7 DATE .... ... <br /> ....... ../'* <br /> ............ ........... ..............DATE ........................................... <br /> BUILDING PERMIT ISSUED ............................................................V <br /> ADDITIONALCOMMENTS ...............................................................................***-- -----------------------------------------*­­­........... ...... <br /> ---------------------------------------I.................................................................................................................... ....................... ...... <br /> ................................................................................................................................................... ................... ---------------------------------- <br /> ------------ ------------------- ............. <br /> ---- . .. . . .. <br /> 1? . <br /> Final Inspection by, Date .5 rf.. . . . ......... <br /> ,410* 0/f IV17 r/9� SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> 1 1 9L 7/77 -1 M <br />