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FOR OFFICE USE: <br /> APPLICATION FOR. SANITATION PERMIT <br /> Permit No. <br /> - - --------- -- (Complet ��rriplicate) <br /> V_ <br /> - -------------------------------------------- y~e 114' Date Issued <br /> --------------------- ------------------ - ------ This Permit Expires I Year From Date Issued <br /> ----------------------- <br /> .1 <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 com <br /> ,pJiance with County Ordinance No. 549 and existing Rules and Regulations: <br /> it :;t t?.49 ke 77 k--— <br /> I <br /> JOB ADDRESS/LOCATION11- ---- -- ------- ---CENSUS TRACT ----------- <br /> Owner's Name /V -1---------------------------------------------------- ----------6-------------------Phone------------------------------------- <br /> Address f -------------------- City ---------------------------------------------------------------------------- <br /> -------------- ----------------------------- <br /> License # Phone <br /> Contractor's Name <br /> Installation will serve. Residence-0 Apartment House El Commercial :[]Trail6r. Court 1E] <br /> Motel 7 Other ---- --------------------------------------- <br /> :X/0-"I-------------------- <br /> Number of living units:J-------- Number of bedrooms _______Garbage Grinder /V0--- Lot Size IAO- <br /> Water Supply: Public Syst' m and name -------------------------------------------------------------- -------------------------------------------------Private E] <br /> Character of soil to a depth` of 3 feet: Sand Silt❑ Clay E] Peat E] Sandy Loom C] Clay-Loam.C] <br /> Hardpan ❑ AdobeK Fill Material ------------ If yes,i type -------- ------------------- <br /> (Plot plan, showing size A f 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 f SEPTIC TANK 14 S i z e 5�_�---11---------------- Liquid Depth ----------------- <br /> 1,2_C76&,4_ Type/PP/7V37 Material Compartments 1;;� JV <br /> Capacity ----------------- 0. <br /> ----------- Prop. Line ------------ <br /> Distance to nearest.. Well rte-----------------------,-----------Foundation <br /> t --------------- el <br /> LEACHING LINE No. of Lines ----------------- Length of each line--10.a----------------- Total Length ,_X4701-------.-•.---- <br /> V Box .... Type Filter Material 4'904�f----------Depth Filter Material l__?-------------I------------------- <br /> :11 ,-stance to nearest: Well -----—--------------- Foundation ------ ------- Property Line _3 _'�7__ ------- <br /> Di <br /> -------- Rock Filled Yes ] No <br /> SEEPAGE PIT Depth --- --57------- Diameter ------- Numbe� __._.-J._-.___---- 0 <br /> Water Table Depth __706�-------------------- ----------Rock Size ------------ <br /> /0 —------------- <br /> --.--Foundation -------------------- Prop. Line <br /> Distance to nearest: Well ---777777:��---------------------- <br /> ij <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Dote ---------------------------------- <br /> Septic Tank (Specify Requirements}. --------------------------------­­--------------- ------------- <br /> .quirements) --------------------------------------------------------------------------- <br /> DisposalField (Specify. Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------1_1---------------------z----------------------------------------------------------------------------------------------------- --------------------------- <br /> - <br /> -------------------------- <br /> ----------------------- --------- -------------- - ------------------------------------------------------------ --- -------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) Joaquin <br /> I hereby certify that I ha I-e prepared this application and that the work will be done in accordance with Son J <br /> County Ordinances, State'�111.aws, 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 /> F <br /> as to become subject to Workman's compensation laws of California." <br /> Sign4d ------------------- ------- - ------- ----. Owner <br /> Title - --------- ------------------------------------------------------------ <br /> By ------------- ------- ----- <br /> /-- - ---- <br /> Vothe—rtha4'n owner) <br /> II R PARTMENT USE ONLY <br /> BY ... <br /> APPLICATION ACCEPTED. ------ - ...... - ---- ---------------------------- --------------------------, DATE ��------------•--- <br /> BUILDINGPERMIT ISSUE.D -------- - ------ -------------------------------------------- --------------DATE ------------------------------------------- <br /> ADDITIONAL COMME --- ---- ----- -- ------------------------------------------------------------------------------------- <br /> - <br /> -) I 1 01 -------------------------------------------------------/----------- ------ - - ___ I. <br /> - <br /> --------------------- ----------------------------------------------------------------------------------------------------------------------------------- <br /> ------ <br /> ----------- ------------------------------- ------ -------- ----------------------------------- --------- ---------------- <br /> ----------------------- ------- ------- <br /> Final Inspection by: ---- ----- - <br /> -------------------------------------------------------------------`--------.Date -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> V <br /> E. H. 9 1-'68 Rev. 5M <br />