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,Fb;Z OFFICE USE- <br /> .--------------------------------------•- _ APPLICATION FOR SANITATION PERM Permit No. ....... <br /> lCom plete InTriplicatell .. .. ... <br /> ........... .............. <br /> t ........ Dote Issued .. <br /> ........I...._._...•............­.................................... This Permit Expires I Your from Date Issued <br /> Application is hereby made to th6 San 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 i-W. ............11,................CENSUS TRACT .......................... <br /> Owner's Name .-Ir.1:5161ax....... ........-----------------­-------­....... .......................... .............___......... <br /> Address <br /> ' __­Awr------------ ------------- .............__y.....:.......-••---••-_._..--_-_._---•city ...I....... ........-........-•-- ........................... <br /> Contractors Name _ 7.;�47f 2t -S45A......License# 1.77�Xd..3.. Phone <br /> Installation will serve: Residence[3 Apartment House 0 Commercial ]Trailer Court 0 <br /> Motel 0 Other ... ............. <br /> , .Number of living units:_ L_ Number of bedrooms ...Tl Garbage Grinder Lot Size ...1A6Xr................. <br /> Water Supply, Public System and nameAWVAI-C--�......................&........................ .................................Private <br /> Character of soil to a depth of 3 fe46t. SandX Silt 0 Clay 0 Peat[I "y Loam-0 Clay Loom <br /> .:.Hardpan[I Adobe 0 Fill Waterial ............If yes,type ............... ...... <br /> (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be 'placed on reverse tide.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> M <br /> PACKAGE TREATMENT SEPTIC TANK Size._...OK ^v ........... Liquid Depth ....h5.4...._.,..... <br /> 1-- No. Compartments -- ----------�­ <br /> Material 4!2a04oXh. <br /> Capacity 2/-V_ V--------- Type <br /> Distance.to nearest.- Well ----150....................Foundation ...,Il_.------.... Prop. Line .-,5............... <br /> of <br /> No. a n e ............... Total Length ------------- <br /> LEACHING LINE f Li4s ................ Length line.....170.- <br /> V Box Type Filter Material AMA......Depth Filter Material .`........•.•-. .... <br /> Distance to nearest. Well _SOO............. Foundation _,_._/.O........._.. Property Line ..ft5................. <br /> SEEPAGE PIT Depth ------1-------------- Diameter ----------- .... Nu'M' ber ............................. Rock Filled Yes (3 No 0 <br /> Water Table Depth ---_--_-----_----------- --------r..Rock Size ......... ............... <br /> Distance to I nearest: Well ................................... ....foundation .................... Prop. Line ................ <br /> R.EPAIR/ADDITION(Prev. Sanitatioh!Permit# ....-•--•=---•••----•--------------•---•--.. Dote ........__............... ...... <br /> SepticTank {Specify Requirements) ............................................:...........................................&................. ............................ <br /> Disposal Field (Specify Requirements) -_---_-------------- .................. --------- ------­......................................................... <br /> ------------------•----•. ----------------------------------_....... ------------------------------------------------------ ....... ............................... ............................ <br /> ---------------------------------------------------------- ------­-------------­11---------------------.......................... ........................... .............................. <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 Un-J604UI" <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health;District. Home owner or liceit• <br /> sod 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 /> Signed ---....................... . -------­----------......*...........­*----- Owner <br /> .................... <br /> By .......... ........... ......... ------- ------------ ------------- Title ....CV7, <br /> ­ �29& <br /> (if-ger than owner) <br /> _fOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ---------------------­..., ...............DATE ........ .. ............... <br /> : BUILDING PERMIT ISSUED ---------------- ............................. ................................................_DATE -----.....-----••--........_ <br /> ADDITIONAL <br /> ---- .............. -ADDITIONAL COMMENTS ........ ......L..................................................... ....... -------------------------•--------------------- <br /> - <br /> ............... ------------------------- <br /> --------------------------------------------- ------------ -------------------------------------- .......................­­............. ---------------------:­­................ <br /> ----------------------------- ------------------ --------- <br /> --------­------ ------ -----------*------------------------------------------------------------ ----------------------- <br /> -------------_-____---------- -------- -- -------------- ----------- --------• ---------------------- 74 ...... <br /> :Final Inspection by- ----------------- dg!-( ------- .......... .............................Date ....... <br /> 'EH 13 24 .1-6 8 Rev. 5M iSAN"-JOAQUIN OCAL HEALTH DISTRICT 8/74 3M <br />