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FOR OFFICE USE. <br /> APPLICATION FOR SANITATIONPermit No. <br /> PERMIT 4 <br /> ........................ ................... i <br /> (Complete in Triplicate) <br />............ ...... ......... <br /> ..................... <br /> This Permit Expires I Year From Date Issued Doti Issued <br />.................................... --------------- <br /> Application is hereby made to the San,Joaquin Local Health Distr'ict jor a permit to construct and install the work herein <br /> described, This application is mod6l'in compliance with County-Ordinance No. 549 and existing Rules and Regulations: <br /> I ` L;V-x <br /> jOB ADDRESS/LOCATION -75.7•------Z _y�J............. ............ ........ ..........CENSUS TRACT ........................ <br /> -- - --------- <br /> Owner's Name -------- ......�•------------ ...... Phone Yj/.72.7-/�2............ <br /> Address .....................ro._- .......... ...................... city ... ................... .................... ........ <br /> Contractor's Name -------------- <br /> . ............................ License # ..... Phone <br /> Installation will serve: Residence 0 Apartment House f'1 Commercial OTraller Court 0 <br /> Motel 0 Oth -n <br /> er <br /> of bedrooms -,.3��arbqge Grinder ............. Lot Size ....................... <br /> Number of living units:.... Number ......... <br /> Water Supply: Public System and name ......................................... ............. .........­......................... .....Private <br /> Character of soil to a-depth of 3 fe6t.' Sand 0 Silt,o Clay 0 Peat❑ Sandy Loam 0 Clay Loam <br /> Hardpan 0 Adobe O'f Fifi_"terlol ............ If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of-system In relation t"01s,buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank_'o_r,see' <br /> page pit permitted if.-public sewer Is available within 200 feet,) <br /> . <br /> PACKAGE TREATMENT.,',j-]- SEPTIC TANK N Size ....................... Liquid N'f Depth ... <br /> TCapaityk <br /> Ty e Materia! ... .. No. Compartments <br /> Distance to nearest: Well _A:5Q...f..............Foundation ............ Prop, Line ...................... <br /> LEACHING LINE No. of Lines --------------- Length of. ea line,...../ /!_T0 <br /> :��,4 (70.............. Total Length ............... <br /> r.7at <br /> 'D' Box __.--------- Type f=ilter Material Depth Filter Material .....I.?............................... <br /> Distance to nearest. Well ........................ Foundation ........... Property tine.. <br /> SEEPAGE PIT <br /> .Depth .............. .Rock Fillid No C3 <br /> Water Table Depth ............_............ ----_-------------.-Rock Size <br /> Distance to nearest: Well .......... CT&..:71............Foundation _-.16--- Prop. Line ..... <br /> REPAIR/ADDITION(Prev. Sanitation Permit ................................ Date -------------------------------- <br /> Septic Tank ISpecify Requirements) .......... .................................................... <br /> ---­----­-----I.,........................................................ <br /> Disposal Field (Specify Requirementsl ----•---..... . .............. ...................... .................. -------- ...... ......... <br /> ............ <br /> ----------------- -------------------------------------------------------------------- <br /> ....................... ....................................................... <br /> -----------------------------------------------------------------------------M_---------------------------_­........ ........... -------------------------------------- ............. ...... <br /> (Draw existing and required addition on reverse side-1, F <br /> I 'hereby certify that I have prepared this application,and that, the work will be done In accordancii with,Son Joaquin <br /> County Ordinances, State Laws, and Rules and lte�gulations of,,the-.Son Joaquin Local Heal&.District. W066 Wrier 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 subiect to Workman's Compensation laws of California." <br /> Signed -------- --- - -----------/:_-�------ ---- ---------------------------- Owner <br /> -_11 1!�� e .................... <br /> By ............ . -1,7. • -----(,__,5.-A � ......... ....... ... . ........ <br /> j................................. ------------ Titte --------------_ <br /> (I oth an owner) <br /> FOR DEPARTMENT USE ONLY <br /> ........... ------ <br /> APPLICATION ACCEPTED BY ----- ...... --------------------------------------------- DATE ...... ...... .... .....6---------------- <br /> BUILDING,,PERMIT ISSUED -------------- . .......................................................................................DATE -------------------------------- <br /> ADDITIONALCOMMENTS ---------------_-__----------- ................... ...................... ------------------ ---------------------------------- <br /> --------------------------------------------- --------------------L-------------- -----------------------------------­---------- -----­--------­-- -------- ----­------I-------­--- <br /> ----------------------- ------------------------------------------------------------------ ------------ ------------------- --- .......................................... <br /> --- ---- - - ----­- ----- <br /> Final Ins p e ction by: <br /> ------ ------ ................. ........................__....... .......Dot ------- <br /> ER 13 21a 1-68 Rev. <br /> Ir SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />