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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ................... <br /> In Triplicate) Permit,No. 2_7... <br /> ........................................ <br /> ---------------- ........................ This Permit Expires I Year From Date Iss-Wed, Date Issued6-;9......_. Z7 <br /> Application is hereby made to the Son Joaquin Local-Health Dittric't' 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 RulesandRegulations: <br /> JOB ADDRESS/LOCATION -­_ ...... . ...............CENSUS-TRACT ........... <br /> Owner's Name ........... 4n.4—---------------- ......... <br /> ..................... ................ <br /> Address ........ <br /> .. ..... .................. ............................ ....... city .... ...................... <br /> Contractor's Name ------- ........... ......License # Phone ....... .. <br /> —CkJ.. se&" <br /> . . ... ... ..... <br /> Installation will serve: Residence PrApartment House 0 Commercial OTraller Court 0 <br /> Motel 0 Other......................_.......9............. <br /> Number of living units:.... ----- Number of bedrooms -----k�Garboge Grinder _.o-Act size .......... <br /> Water Supply: Public System and name ------------------ ........... . .....Private ❑ <br /> .................... <br /> Character of soilf6a depth of 3 feet: Sandt] SiltC] ClayO Peat[] .Sandys 6a.rn.0 Clay.Loam,o <br /> Hardpan 0 Adobe Fill Material ........if yes,type _............ .......... <br /> (Plot plan, showing size of lot, location of system in relation,fo wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit,�ermlttecl if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f J SEPTIC TANK I —Size................................... ............. Liquid Depth _................. <br /> -.-,Capacity <br /> ------------I—— Type ---- ............ Material.............. ....... _No._Compartments ...................... <br /> �i I !J <br /> Distance to nearest: Well ....................................Foundation ..................... Prop. Line ..... ................ <br /> LEACHING LINE, No. of Lines -_.__.__1._._..._-_._- Length of each line....... --- Total Length, .......... <br /> V Box ..__l__... Type Filter Material _5;F��505-Depth Filter Material .............../<r <br /> ... ........../<r .................... <br /> L&IC9 5442,0 Distance to nearest: Well ................ Property LineS. ............ <br /> Depth ...../Z......... ...... <br /> Number ----..__-_--/............. Rock Filled Yes,9 No <br /> Water Table Depth _---------_-- 0 .. ... Ok <br /> . _0 ­ ­ <br /> ------------- - ---­Rock Size .........".11..... <br /> Distance to'nearest- Well ......_W_4)/V..................Foundation .... ...... Prop. Line --•--•'S',•--.---• <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _.:....................................... Date ..........................­------ <br /> Septic Tank (Specify Requirements) ...... ............ki................................................... ................... ...........I........... ........... <br /> Disposal Field (Specify Requirements) ---- -----------------------------------------------------I............ ...................................... <br /> I 1 11 <br /> --------------­__--------------------------­­....... _ _....----"------••-------- ...... ...........I..................................... ...................... ----------------- ............... <br /> ----------•......I---------------------------------------------------•----••----------------- ------------..............I............. ................................ .............. .......... <br /> .(Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and th at,,1h.9_work_wiII,.be.done in-accordance-with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son 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 %hall not employ any person In such manner <br /> as to become subject to Workman's'Compensation laws of California." <br /> Signed ----------- 77,0=7 <br /> .........._V,4 wner <br /> � <br /> By ---------- Title --------_----------_---- - ............................. .......... <br /> ....... <br /> (If other than-owner! <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED.IBY - -- ----------••----:------------- ---------------- ----------- DATE <br /> BUILDING PERMIT ISSUED• <br /> ----------- ---------- ... --- _ . ... ..-.. ......r. <br /> ..................-I......7....................... <br /> ..... <br /> . . ­ . ...... ...... ------------------- ................................. ........ADDITIONAL COMMENTS ------------­--------- - - . . — \ <br /> -------------------------------••- ----------.._.-_.. . ...... ----------------------------- ,. . X . <br /> I <br /> •.--------•--•--••-•-------------------------------------- ....... --------------------- - ---------I---------------------- ----------------- -------------------- .............................. <br /> ----------_----------­- ................. ---- -- ....... ........................I...... ................ .......................... <br /> Final Inspection by ............ ------------------ <br /> . . . .. .......­................. .............................. ......Dot <br /> EH 13 2h 1-68 &_,v. 5 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 8/7h 3M <br />