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FOR OFFICE'USE: APPLICATION FOR SANITATION PERMIT <br /> ---•----------------------••-•---•--............. /4- <br /> .......................A ................ . <br /> (Complete in Triplicate) <br /> Permit No. ..................... <br /> ....................... ........ .......-..... This Permit Expires I Year From Date issued Date Issued <br /> Application is hereby made to the Son Joaquin Local Health Distrid 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&e ......CENSUS TRACT --.-................ <br /> Owner's Name ---- <br /> e ------- . ..............................­•-•-•-............ . ............Phone .......... ...................... <br /> Address <br /> -7 .............. .. 3— 1----- .. V1 0-,-c------- C1, --...._,.............................-.............•-•-- <br /> Contractor's Name .... ... # le..Y.3 kl.�.... Phone .............................. <br /> Installation will serve: Residence ET'Apartment House(] Commercial [:)Trailer Court 0 <br /> Motel []Other............................................ <br /> -z <br /> Number of living units:....... Number of bedrooms .... ..._Garbage Grinder ............ Lot Size ......................................... <br /> Water Supply. Public System and name ....................................... ......... .....................................................Priva,te <br /> Character of soil to ci depth' of 3 feet: Sand 0 Silt❑ Clay 0 Peat 0 Sandy Loom 0 Clay Loom 0 <br /> ' , <br /> Hord p65- <br /> OUAdobe ❑ Fill-A&!dt-- <br /> ..... If yes,type ............... ............ <br /> (plot plan, showing size of lot, location. of system in4'relation,to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or,seepage permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT [ J SEPTIC TANK-1 I -ilze................................................� Liquid Depth .......................... <br /> -J <br /> Capacity --------------------- Type .................... Material........--......... No. Compartments .......................%y <br /> Distance to nearest: Well ------------Foundation ...................... Prop. Line ------------------- <br /> LEACHING LINE No. of Lines .............. Length of each line---------------------- ...... Total Length ............................ <br /> 'D' Box ------------ Type Filter Material ....................Depth Fitter Material ............ ....................... <br /> Distance to nearest. Well ......---..f--..._------ Foundation ........................ Property Line ....................... <br /> SEEPAGE PIT, Depth -------------------- Diameter ............ .Number ..................... ...... Rock Filled Yes 0 , No <br /> Water Table Depth --------------------------- ........ ...........Rock Size ............................. <br /> Distance to nearest: 'Well ......................... ..............Foundation .................- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........I....-- ..................... Date ..... .......................... <br /> Septic Tank (Specify,Requirements)........................ .................. <br /> -... .... z .....;.. ..._.......-•------..................---..... ...... <br /> Disposal Field (Specify Requirements) ---6-Z-e--U---- . .. . .......... <br /> .. . ... ... <br /> ............... <br /> .. .. ------- <br /> ............................................. ..... <br /> .... . ...... <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 done In accordance with Son 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 shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------=------------ -------------- ........ Owner <br /> By ----------------------- ------------------------ Title ... ........................................ <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... -- ---- ------------I............ - - - DATE . / - .... . <br /> BUILDING PERMIT ISSUED --------------•---- •-• •- -- ----------------------DATE -.................................... <br /> ...... <br /> ADDITIONAL COMMENTS --------------------•---• --------- ------------------------------------ <br /> --------------------I------------------ ------------------------------------- --------- .................................................................... ............ <br /> ---------------------------------------------------------- ---------...---------•-------------------- ---------- -------------- <br /> ---------- <br /> -------------- .............................. <br /> ------------------------------------------------------------ ...........Date A ....... ...... <br /> Final Inspection by: ----------- .... . - ------- .. .. -------------------- <br /> ------ -- -- -------------------------------------------------------------- ------------ <br /> EH 13 21,E 1-68 1-bev. 5m OAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />