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Km office Usti <br /> APPLICATION FOR SANITATION PERMIT <br />......................................................... . <br /> (Complete In Triplicate) permit <br />............................I............................ <br />... ..................................................... This Permit Expires 1`Yoar_ iroin'664 Isived Deft Issued ...... <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 Wth County,Ordindnce No. 549 and"existina Rules and Regulationst <br /> JOB ADDRESSA'OC�1A_TION_1 %9e. 4... C . .............................— ... ....... ........... ..... . .....CENFS <br /> US TRACT ............ .. <br /> Owner's NameX . ...7...` <br /> . . P.. .... ......I........I.... . .............. ............. ..........Phone <br /> ?94r.�.ef FP........ <br /> Address .... .... ........ ....... ............................................City .......... . . ... ............................,c ................. <br /> ,9 Phon . . ... .. ....... .. <br /> Installation will sere®: . . . <br /> Contractor's Name . . ......................... ........................License # <br /> Residence g3-Kp'artment House 0 Commercial OTraller Court 0 <br /> / <br /> Motel 0 Other.............................__7........... <br /> Number of living unitss.'......... Number of bedroaam .......Garbage Grinder ............. Lot slie ............................. <br /> Water Supply: Public System and name .................................................................................. . ....................Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay 0 Peat 0 Sandy Loam 0 Clay Loom 0 <br /> Hardpan 0 Adobe 0 Fill Material ............ If yes,type........................... <br /> Mot plan, showing size,of lot, location of-system In relation to wells, buildings, ate. must be placed on reverse side.) <br /> NEW INSTALLATIONS No septic tank-or seepage pit permitted If pubf Ic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK I Size................................................ Liquid Depth .................... <br /> Capacity -------_---------- Type .................... Material...:..........._. No. Compartments .....................k . <br /> i. f ' <br /> Distance to nearest: WeJIL ....................................Foundation ...................... Prop. Line ..................... <br /> ro <br /> LEACHING LINE, No. of Lines ........................ Length of each line. ................I...... .Total LengthA;!.ZC............ <br /> Box ............ Type Filter Material ....................Depth Filter Material ............................................ <br /> Distance to nearests Well ......................... Foundation .......................... Property Line ........................ <br /> E P <br /> SEEPAGIT Depth ------------- ...... Diameter ................ Number 7........................... Rock Filled Yes C3 No C30 <br /> Water Table Depth ----------_----- .............................Rock Size ................................. <br /> C <br /> ( D-Istance to nearestt Well -............. .....................Foundation .................... Prop. Une ..............I....... .REOPA�jDiT'1'04(Prev. Sanitation Permit# .................................. Date ............................ <br /> '**V0PPt_ic Tank {Specify Re:quirements) ................... 7............. ...................................................... .........a.. ..................... <br /> DwIcisal Fiala' (Specl 7q4ullyments)I .......................... . ........... <br /> ................ ............................................................ <br /> ................. ... .. ..............................................I...........I....­­................ <br /> .............................................. <br /> ..........................................w............. ...................... <br /> i <br /> ­­ ­' <br /> (Draw---w---existing- "--, -n"d, required.d-...addition d1t1*nonreverse 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 Lows, and Rules and Regulations of the Son Joaquin Local Health District. Home owner w Men- <br /> sod agents signature codifies 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 beconyq 7ubact to rkman's Compensation laws of California." <br /> Signed .... .. .......... �/............... Owner <br /> By ................. Yitle ..........................7 .......................................... <br /> Ili other than owner) <br /> -FORAEPA OMIENT USE ONLY <br /> ......... . .. .. ......................... ............................. DATE <br /> APPLICATION ACCEPTED BY.............0 <br /> BUILDING PERMIT ISSUED,!.................. ...................... <br /> ----------------------- .............DATE ................................ .......... <br /> ADDIT100AtCOMMENTS .......................................... ................................... ........................... ................................. <br /> . ............................. .................................................... ..............­....... ........ ............................................ .............. ...................... <br /> ............................................................................... ......................... ...... . ........... <br /> ................................... ..................Irl....... . .........1,..........� :. . .7............... <br /> FinalInspection by. ................ e_rtze,", ......................................................Date ........ ..2 ........... <br /> EH 13 24 1-68 Rev. _qj <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H <br />