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.AR OFFICE USE:` <br /> APPLICATION FOR SANITATION PERMIT <br /> "_......_I._..�I— F.P....- 74�, <br /> Permit No. ..................... <br /> (Complete In Triplicate) <br /> ......................... <br /> ..................... <br /> ..- Doti Issued ;5.�. <br /> .............%.:................ This Permit Expires I Year from Date Issued <br /> Z . . ................._J <br /> Applicatlon 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 /> pp r <br /> .. . ....... . <br /> JOB ADDRESS/LOCATION Jlkl.... ....... . .. ..... . .......... .......1-1.....CENSUS TRACT .......................... <br /> Owner's Name ......... _ . .......................Phone ,? <br /> 7 p. <br /> Address -- ------------- ...... Ci - --•--- ....... ............ <br /> .. .. ........... "t City <br /> --- Phone <br /> Contractor's Name ----------------4------ --- . ......4... .... ..... ......License <br /> Installation will serve: Residence qApartment House C] CommiercialoTraller Court :b <br /> Motel 0 Other....... .................................. <br /> Ndmber of living-un its:-.--. ..... Number of bedrooms _.__....Garbage Grinder .........._ Lot Size ...................... <br /> Water Supply: Public System and name ........ ..........................................-- -._............_................................_Private <br /> Character of sail to a depth of 3 feet: Sand 0 Slit 0 Clay 0 Peat,[3 Sandy Loom C] Clay Loom 0 <br /> Hardpan 0 fill Material ............If yes,type ...... ........ ....... <br /> (Plot plan, showing size lot, location of system In relatiori'to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No-septic tank or seepage pit permitted If public sewer is available within 200 feet) <br /> TIC TANK t4 Size._..._.t ...... Liquid ....... <br /> PACKAGE TREATMENT<[ SEF Depth ..S <br /> Capacity Type ......04."F Material...(f eto No. Compartments ...................... <br /> -------------------- <br /> I _' Distance to nearest; Well .......... ...... Prop. Line ...................... <br /> ittk t .... , JdD 1.9 .. . e. <br /> > ,No. of-Lir =Length of each4lhe.. ............. Total <br /> LEACHING LINE ies- ...... ... Length .17.0................ <br /> V Box ---A----- ---Depth Filter Material ......... ....................... <br /> .. ..... Type Filter Material <br /> Distance to nearest. Well ...... Foundation <br /> .......5�&114 ----/¢_.'�"....... Property Line ....�E............... <br /> SEEPAGE PIT Depth ....?r Diameter Number -------------------------... Rock filled Yes No <br /> Water Table Depth . I.................................................Rock Size <br /> 4- <br /> ..Foundation ...... <br /> Distance to nearest. Well ...... .... ... Prop. Line ------- <br /> REPAIR/ADDITION(Prev. Sanifatio"n Permit# ........... ................................ Dote ..................................I <br /> Septic Tank (Specify Requirements) .......................... ............................ ....... ....................... <br /> Disposal Field (Specify Requirementsi .... ......... ........... ......................................................... ............... ••-•--.._._..:..:.........••••-- <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 "j <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health:District. Home owner or licew <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 /> ------- ---- <br /> BY .. ...... -------- - - --- ------- ---L------- ------ ..........I-------- Yitle ........ - <br /> (if other th wn.er) <br /> VDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... ......_ L....... DATE . ................. <br /> ............... ........................... <br /> BUILDING PERMIT ISSUED ........ ... .......-- --- - ------------- ------ --------..-..----•-----•---------------.DATE - ----- --_------------ ........ <br /> ADDITIONAL COMMENTS ---- I <br /> ­­-------------------------------- .... . ................................................ <br /> --------------------- ---- ­ ---- -----------------------------------------1-------- <br /> --------- --------- -----­------------ ----­------------------ <br /> ------ ----------------------- - -- - ---- - ------ ---------------- --------------------I-----­-------­---------- ------ ...................................... <br /> ----------------------------------------------- - ------------------------.1-1................................................................................... <br /> Final Inspection by: ....... - - - - - -- .. .... ............. .................................. .............Date ... ......... <br /> EH 13 24 1-68 S.. JO UIN LOCAL HEALTH DISTRICT 8/74 3M <br />