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FOR OFFICE US <br /> E• APPLICATION FOR SANITATION PERMIT <br /> 71 <br /> ............ .......... Permit No./&/ <br /> lComplefe In Triplicate) <br /> .......... ......... ...... .............. <br /> Doti <br /> This- Issued I Year,From Dote-Issued -issued <br /> ............... .................................... <br /> Application is hereby made to the Son Joaquin Local-Health District for a per'mit 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 /> ]IOB, ADDRESS/LOCATION...........i3k..4.a �,................... <br /> ..............................CENSUS TP.ACT ......... ........... <br /> Owner's Name .------ ...... ..............Phone ...... ..................I....... <br /> CQ <br /> Address ............................ - -------- ... .................... ........ ........................ <br /> ...... . <br /> Contractor's:Nomi ... .. .. ........ .. --- .......... .................License # �P2<S� Phone ...... <br /> 0 <br /> Installation will serve: Residence partment' House 0 Commercial OTraller Court <br /> Motel t:j Other .................... <br /> ........... <br /> Number of living units:... Number of bedroom Go bag Grinder ...... Lot Size <br /> .y <br /> ./,5 V <br /> .. ................ <br /> Woterl Supply: Public System and name ------ ----- . ... ....... .. .......................•---................_ .Private 0 <br /> Character of soil to a depth of 3 feet: Sand r] Sil 0 Clay 0- Peat[] Sandy Loom 0 Clay Loom 0 <br /> Hardpan 0 AdobeFill M4terIaI_,V. ..P...If yes,type ............... ..... <br /> (plot p!an.,—slidwing size of lot, location of system ,'In relation-40- wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic-tank or seepage pit permitted if pu6ilc sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I ] SEPTIC TANK f Size...................................... ..........Liquid Depth ..................... <br /> Capacity ------------------ Type .....-......---:-•.. Material-_------------------ No. Compartments ...................... <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 filter Material ........................ ................ <br /> Distance0o-nearest: Well ------_--------- --- Foundation ........................ Property Line ................... <br /> SEEPAGE PIT -Depth ...........j ---- Diameter ------------_- Number -------------------------_ Rock Filled Yes 0 No <br /> .,,,Water Table Depth •----=--=•-•---.......- Rock Size .............•-- <br /> } <br /> Distance-to nearest. Well --- ------_-------- ........Foundation ............ ....... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev'..Sanitation Permit# .......... ----------- Date ----------------------------------I <br /> Septic Tank�(Specify Requirements) -------------------- ....................­...... ------ ........ .......... ............. <br /> Dis osol Fed (Specify Requirements) ------_----- <br /> --------------------- -------- --------- ------ ........ <br /> p A ---- ---A-- <br /> 109p�----------------------- <br /> -------------------------------------------------------- _-yV_ox .Si <br /> .......... ................................ ................. ................... <br /> --------­-- --------------------------------------------------------•----------------------•-------------.--------- ......................................... ........................................ <br /> —­---(Df-a%v existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be don6 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 ------------- <br /> ......... ..................................... Owner <br /> By -------------------- - ------ <br /> --------- ------------------------------------7---------­1... Title ... . ... .. .. . <br /> f eir than ownerl <br /> L—FORDEPARTMENT USE ONLY <br /> ------------- ...... ------------------- --------------- ------------- <br /> ----------DATE ................ <br /> APPLICATION ACCEPTED BY ----- <br /> BUILDING PERMIT ISSUED .............. .................... --------------DATE --------_--- ...................... <br /> Z�---------------I---- --------------- <br /> ADDITIONALCOMMENTS ----_-------------- .............................. :-.....--..._^..------ ............. ........................ .................... <br /> ------------------------------­..........................................................................:.................................... ...........................I—------I�............ <br /> ------------------------------------------------------- ............................................... --------------------*---- ------- ----*............ ........... ......*--------- <br /> ------------------------------------------- -- -------------- <br /> Final Inspection by.. <br /> ---------- - <br /> , -------------------------------------------------------------------------Date ................ <br /> EH 13 24 1-68 Rev. 5M SAN JOAQUtN 'LOCAL HEALTH DISTRICT 8?7h 3N <br />