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FOR OFFICE USE: ............ _ ......... -------------- ---------------- 7 ------ APPLICATION FOR SANITATION PERMIT )Complete in Triplicate) This Permit Expires 1 Year From Date Issued Permit No. Dote Issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and e;4i i Rules f d Regulations: C _ ,�n7�g_ Z�---------------- CENSUS TRACT .... JOB ADDRESS/LOCATION -- ---- - -------- Owner's Name ----- klw-1:7-,O�--C ....... ��6 -- --------------------- -------- --------- ...... Phone ------ Address ---- ------Z- VP ---- ---- city 0# -------------- y s 6 t4 _,,7 -..License e ...... Contractor's Name 1-7 . ...... Installation will serve: Residence 0 Apartment House 0 Commercial []Trailer Court C] Motel F-1 Other ....... 4941111 --- Number of living units:._.----.___ Number of bedrooms ________.Garbage Grinder .... ....... Lot Size ...... --------- I Water Supply: Public System and name --------- ------- --------------- ------- ---------------------------------- ........... Private/K I - 111� Character of soil to a depth of 3 feet: Sand E] SiIX Clay El Peat 0 Sandy Loam 0 Clay Loani4j�— Hardpan 0 Adobe X Fill Material - ------- — If yes, type ................_--.-. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must �be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT LEACHING LINE [ I SEEPAGE PIT [ I I SEPTIC TANK T I Size--- ------ r Liquid Depth --------------- Capacity ..... Type A.,n-e,47,-Material ---- ? ------ No. Compartments ... Distance to nearest: Well ----- --------------- Foundation b Prop. Line No. of Lines ...... ...... ...... Length L -- of each 1;— / A Total Length ..-9n9........._._..-- ...... y 'D' Box �, e . ...... Type Filter Material 5q,7,.c .. fl.6,#fpth Filter Material -_---_P ----------------------------- Distance"to nearest: Well Foundation A-Y.�el --- 1-0-/ ---- Property Line _-.169.`_.__.--._-. Depth Diameter ...... Number ..... Rock Filled yes No 0 Al- - Water Table Depth ----------- 40--r ---------- ---------------- ..Rock Size --------------- i .......I------ A-4�,J t1r; I r—rldation 1 Line ... L �Q._'-_-___-__ Distance to nearest: Well � ------------------- ---------- REPAIR/ADDITION (Prev. Sanitation Permit # ........ --------------- I ------- Date ---- Septic Tank (Specify Requirements) --------- ----------------------------------------------- -------- ---------- ---- ------------------- Disposal ---------------Disposal Field (Specify Requirements) ............. -- - --- ---------------- - -------------- ---- ------------ ............... ------------------------------ ... ....... ----------- ............................................ ------- --- ................ ... .. ------------------- ----------------- -------------- .. .... ...... -- ----------- ------ — ------ -------- ------ - ------- ------ ------------- -- --------- ------- ; r.-JDra�v existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules -and Regulations of the Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the followirilf "I certify that in the performance of the work for which this p@rmit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ........... 6; -------- Owner , V 'Title ----- ------ -------------- By ................... -- - (If other than owner) DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- --------- ---------------------- DATE .... "~=•.........• BUILDING PERMIT ISSUED ------------------ ................................... --.DAT�Z --------------------------- ........... ADDITIONAL COMMENTS 4 Ay Li -------- 4ed o- . . ...................... ---------- ------------ — ..................... 117 , Z.--- -------- ............ -- ...... ...................... -------- --------- ----- - .............. ------------------------------------------------- --------------------- ---- ------- -- ----- 1---b --- -------- ----- -- -- - ------------------- ---------- ........................................ --l—.— ------------------ ------ ------- Date ... ...... Final Inspection by . .................. ---- - -- SAN J AQU LOCAL HEALTH DISTRICT E. H. 9 1 -'68 Rev, 5M