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---------------M,-R-----0 FFI-CE U-----•------S E:--------------- APPLICATION FOR-SANITATION PERMIT Permit No. ll <br /> (Complete in Triplicate) <br /> --------------------------- ------------- <br /> This Permit Expires I Year From Date Issued Date issued <br /> ---------- __G/- 7�. <br /> -------- <br /> Application is hereby made to the Son 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 /> ------------w....... <br /> JOB ADDRESS/LOCATION .-----o ------Oar--- -- -- --- - ------- ENSUS TRACT <br /> Owner's P one .3* <br /> wner's Name 11% 44------------- --------- ------------- --- ---- <br /> ... ----------- <br /> --------City ��----- ----------------- <br /> Address ----w_1_ZJ9---------------k-------�V - ?--------- Phone <br /> ... ----------- --- <br /> Contractor's Name -------4�� --- ------License ---- -- ---------- --- --- ---- <br /> Installation will serve: Reside nce,�`Apa rtment House-[] Commercial ;E]Trailer Court IC3 <br /> Motel n Other ----------- ------ ------------ <br /> Number of living units:_-__ Number of bedrooms __.y4k___Garbage Grincler/16� Lot Size ------ ------- <br /> Water Supply: Public System. and name ------ -------------------- ---------------- Private E] Z, <br /> - <br /> Character of soil to a depth of 3 feet: Sand'[:] Silt E], Clay [:1 Peat El Sandy Loom E] Clay Loam .E] <br /> Hardpan Aclobe;Fkr', Fill Material ------m----- If yes,type ---------------------------- <br /> (plot plan, showing size of,'06t, location of system in relation to well s,:.b61ldings, etc. must be placed on reverse. side.) <br /> NEW INSTALLATION: (Ncseptic tank or seepage pit.permittid if public sewer is available within 200 feet,) <br /> PACKAGE,TREATMENT f SEPTIC TANK f .T_':rizee-----------------------------------•------------ Liquid Depth ------_------- - <br /> f <br /> Ca <br /> -----m------------------- <br /> Ca :Lity ----w-----------.--- Type ---------- Material------w--------------- No. Compartments ------ ---------- <br /> p <br /> Dist.once to nearest. Well ,------------------------------------Foundation ---------------------- Prop. Line-- ---------------------- <br /> --- -----4_e� <br /> LEACHING LINE No, of Lines ---- /------#------- Length' of each line------4,e - -------. Total Length cl ---------- <br /> 'D' Box ----- Type Filter Material -Depth Filter Material ___Z_57__`'_'________________________ ' <br /> r <br /> Distance <br /> --Z-57------- ------------------------ <br /> Distance to nearest: We'll e_447_AnFoundation ------- Property Line --------- <br /> SEEPAGE PIT Depth <br /> 11----- Di6meter - Number ------ -- <br /> /- -------- Rock Filled Yes No 0 ' <br /> Water Table Depth --------- -------------------------------Rock Size ----a_W------------------ <br /> .01 <br /> Distance to nearest: Well A,-'17 ------ Foundation _--_moo________ Prop. Line ..... <br /> RtPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---w---------------------------- <br /> SepticTank (Specify Requirements) -----------------WW--------------------------------------M_---------------------------------------------- --- ----- -------- <br /> Disposal Field {Specify Requirements) ---------- <br /> -------------------------- ----------------------------------M--------------------------------------- --------W-------M-------------------------------------------------------------------------------------------------------------------------------------- -------------------------------m-------------------M----------------------W----------M--------------------------------------- <br /> (Draw existing and required addition on reverse side) i <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 <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 --------------I---- --- ------------ -------------- ------- Title ----w----- ------------ <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- ------ ------------------- --------------- DATE --------------- <br /> BUILDINGPERMIT ISSUED --------------------- ----------------------------- ----------- ------ -------------------------------DATE ------------------------------- ------ <br /> ADDITIONAL COMMENTS ----------------------------------------------- --------------------------- ----------W-------- ------- <br /> ------------------------------------- --------------------------------------------------- ------ <br /> ------------------------------------------------------------------------------------------- <br /> ----------------------------W----------- ---------------------------------------- ----------------------------------------------------------------------------WW-------------------------W----------- <br /> --------------------------- ------- ----------W------ - <br /> - ---------------- <br /> ---- - - <br /> Final Inspection by - ------ Date - <br /> --- <br /> --- <br /> SAN JOAQdIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />