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FOP, OFFICE USE. <br /> ...........;t..................... .............I...... APPLICATION .FOR SANITATION PERMIT <br /> Permit No. ........75- <br /> ............. <br /> (Complete In Triplicate) <br /> ........... . <br /> ........................... .....Z.. This Permit Expires I Year From Date Issuo I d Date Issued ..�.-7-7 <br /> Application is hereby made to the Son Joaquln Local Health District for a permit to construct and install the work herein <br /> described. This application is made incompliancewith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADqRVSS/LOC1ATION�_ X.O.41<' ...... ..................CENSUS TRACT .........._1------- <br /> OwnerVName . .... .. ...... ............................ .................. ..........11......................Phon!. .......................... ------- <br /> s <br /> Addrei r19!7. City ...... <br /> ..........I.. ...... ............ ......I'dw.................­......................... <br /> .......... . <br /> Contractor's Nome .....)2144S401:w..............................License Phone <br /> Installation will server Residence bApartment Houseo Commercial ]Trailer Court 0 <br /> Motel []Other........•................................ <br /> Number of living units------------- Number of bedrooms Lot Size ---•..-_._•._-•-- ................... <br /> Water Supply: Public System and name ............................. <br /> ..........................................................................Private <br /> Character of soil to a depth of 3 feet- Sanciff"O'SiltO ClayO PeatO Sandy Loam o Clay Loam o <br /> Hardpan 0 Adobe 0 Fill Waterial ............ If yes,type............... ............ <br /> IPlot plan, showing size of lot, location of system In relation to wells, buildings, ate. must be placed on reverse sildel <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer Is available within 200 feet) <br /> PACKAGE TREATMENT I ] SEPTIC TANK i Size...... ............ ................ ........ Liquid. Depth}-_-__ <br /> Capacity ........... Type..................... Material---------------....... No.. Compartments ...._._....... <br /> Distance to nearest: Well ....................................Foundation ...... ........ ..... Prop. Line ......................vo <br /> LEACHING LINE, No.'of Lines .............. Length of each line............................ Total Length ................. ...... <br /> V Box ............ Type Filter Material ....................Depth Filter Materioh�......................1­1............. <br /> Distance to nearest. Well ...,.................... Foundation ---------_------ ...... Property Line -_....... .............. <br /> SEEPAGE-PIT Depth -------------------- Diameter ......... ....... Number ............................ <br /> Ro6k Filled Yes ❑ No C)O <br /> Water Table Depth ... .......................... <br /> . ._... ... R ock'Size <br /> .......................... <br /> Distance to nearest. Well........................................Foundation ...................... Prop.,Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ................ ........................... Date ...4..............................r <br /> ...........a _ ...................L,............................... ................ <br /> Septic Tank (Specify Requireme - ---------- <br /> e 4 - <br /> Disposal Field (SP 'cify Requirements) ....... _W.c....... - ------------ <br /> ............�_11X.1....4.Q1..T. <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- San Joaclulft <br /> County Ordinances, State Laws, and Rules and Regulations of the San Jacticluist Laical Health,,District. Horn* owner or liven. <br /> sed agents signature certifies the following- <br /> "I certify that in the performance of the work for whIA this'permit Is issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of Cal-1 fe,rnio." <br /> Signed --------- --- ----- Owner <br /> ----------------------- <br /> ------------------------------*­---------------- Title ---- ----t .......r........ <br /> By --------- <br /> (If other than owner) <br /> ----..-.FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPT'ED ...---•------------•-•-----------------------_ ---------_- DATE ------------- <br /> BUILDINGPERMIT ISSUED -------------------------•----------------._._...--- ....................................................DATE ... --------------------------------------- <br /> ADDITIONAL COMMENTS .--..--•--•--------------------------- <br /> ............... ---------------- ........................ ................ ----------------1.111--------------------------------- --------------------------------------- ------------- <br /> --------------------------------------------------------------------------------------- ............I-----------­1­_­__­----------­------ ---- --­-------------------_--- ............. <br /> -------------------------- -----------------*....... ....... ----------- <br /> Fina Idw------------------------------------------------------------------- <br /> - `----------•-•- -------------------•--•-----•--•--------------- ---------- <br /> I Inspection �y; ........................../-- <br /> -------_------ ate ....... ... .......­............... <br /> EH 13 2L 1-68 I?,-,v. 5M SAN JOAQUIN LOCAL HEALTH D`ISTiRI'CT 8/74 3M <br />