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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit. No, <br /> N <br /> ­ --------------- - <br /> Doti lssued ..!�.-AZ:7:4 <br /> ..--- This Permit Expires I Your From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and Install the work heroin <br /> described. This application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRIESSACC TION .. .....................................CENSUS TRACT _........ .............. <br /> Owner's Name <br /> /7-1 ­.....-.... ....... i..............Phone ................................ <br /> Address -7.4-e..... .... .............. <br /> Contractor's Name .... _Ucense # Phone ................ ............ <br /> Installation will serve: Resichiriie C(Apartment House Uyl&mmercioll OTrallor Court 0 <br /> Motel 0 Other........ ................................... <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size ........................................... <br /> Water Supply: Public System and name ........... .................... ......I.........................­­­...................Private 0 IZZN <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0, Clay 0 Peat 0 Sandy Loom 0 Clay Loom 0 <br /> Hardpan�/ Adobe 0 Fill M7cterlal ............ if yes,type ............... ............ <br /> (Plot plan, showing,size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse side.) ) <br /> NEW INSTALLATIONI. (No septic tank or seep ge pit permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEF 70 ........... ....... Liquid Depth ..... ... <br /> Capacity, 16.00-rd Type Material. No. Compartments <br /> ................ <br /> Distance to nearest:'Well .......... ...14-t .......Foundation ..... Prop. Line .... <br /> 15 once <br /> LEACHING LINE ftf No. of Lines .........5............ Length of each line.......q.q.I-Y ........ Total Length ... ....... <br /> Box....../...... Type Filter Material ----- .......Depth Filter Material .....:/..f................................ <br /> Distancetonearest: Well ......LO-a-l-r- Foundation ......I-V.1-e...... Property Line ..>57K........... <br /> SEEPAGE PIT Depth Diameter . ....... Nii6ibir—.=_3............... Rock Filled Yes <br /> Water Table Depth ............. Rock Size I ......... <br /> Distance to nearest: Well'.. ......—Foundation Prop. Line <br /> IF.............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................ ................Date ............... ............. <br /> Septic Tank (Specify Requirements) ........................................................................................... ...................... ................. <br /> Disposal Field (Specify Requirementsi ..................... ......................... ........................................................ ............................ <br /> ............ ...................... ----------------------------- ...........I.......---- - ............... ........... ............................................­:1...... <br /> ...................... --------- --------------- ' <br /> ....... ........................ .. . ................*........ ..... ................... ..............*......... ....... <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 doris"in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health.Dishid. 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 shelf net employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -.......... ...... ........... ---------- Owner <br /> By ....... ......._jif other-- . -..than- - . ..ow.owners <br /> ... Title ...... ...... <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . .. . .... DATE 7-- ...... <br /> BUILDING PERMIT ISSUED .... <br /> ......... ............ ....... ........................... --- -- -- ......... ...............DATE . ... .. .. <br /> ADDITIONAL COMMENTS ................................ <br /> ..... ............. ................................................. ............................ ............ .......... .......... ................... <br /> .......................... ................................;................................... ............ .._.._.......I......._......._ _...._................. ...... .....*. ....... <br /> F,n- a I Inspection-*b-y;- ---------- ...... <br /> ...........................................................................................D ................ <br /> EH13 2h 1-68 aev. 5m '9 0 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/71; 3M <br />