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,..FOR OFFICE USE: 3. <br /> APPLICATION FOR SANITAT10" PERMIT <br /> .......................•----._...... <br /> (Complete in Triplicate) PermitNa. 2r�6OP" <br /> .......... ............................................. lb <br /> .0e . . Doti Issued <br /> ..........I——.................. .................. This Permit Expires I Ye6r From Date Issued <br /> Application is hereby made to the Son Joaquin 1.6cal Health Districf for a permit to construct and Insti 1 311. the work herein <br /> described. This application is made in compliance with County'Oidiilance,No. 549 and existing-:Rules and Regulations: <br /> kTI N .....................................CENSUS TRACT . ...... <br /> JOB ADDRESS/LOC� �t------ AV <br /> i. <br /> Owners Name ...01 w..... <br /> ...........................•--__.--,...--•----- ..... --------Phone //%5 ...Z.#­ <br /> Address i 70. _4110. .............City .... ...... <br /> Zj5v�o;------------ <br /> Contractor's Nome6 . .................i ..License # .3!? Phone .....&f. --------- <br /> Installation will serve: Residence artment House 0 Commercial OTraller Court 0 <br /> Motel ❑Other........................... ....... <br /> -Number of living units_____________ Number of bedrooms _-3...__Garbage Grinder __..........Lot size ­................. ........ ...... ........ <br /> Water Supply: Public System and name <br /> ......... ......................................................_­....... <br /> ..................... <br /> .Private <br /> 4L <br /> Character of soil to a depth of 3 feet: . Sand 0. Silt 0 Clay 0 Peat 0 Sandy Loom0 Clay Loom 0 <br /> Hardpan[:I Adobe 0 Fill M6terial ...........t.If-yes,-type................ ........... <br /> (Plot plan, showing size.of lot, location of system In'relation 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK[ Size...—................................:.......... Liquid Depth ......................I__ <br /> Capacity -------- ........... Type .................... Material................ .......�No. Ccimpartments ....................... <br /> Distance:to nearest:.Well .....................................Foundation ...................... Prop. Line ..............*...... <br /> A <br /> LEACHING LINE No. of Lines ........................ Length of each line...............:. ....... Total Length ............................. <br /> 'D* Box ---- ....... Type Filter Material .............. .....Depth filter I-Matertal ....... ...................... ............... <br /> Distance to nearest. Well ................. ...... Foundation ........................ Property Line �............ ........... <br /> SEEPAGE PIT "Depth ---------------­.-.. Diameter ......... ...... Number .......i............ Rock Filled Yes <br /> 0" . No OV <br /> Water Table 0ep-th y -----------------------------------Rock Size .......... ..................... <br /> Distance to nearest: Well ........................................Foundation .................... Prop. -Line..........................I <br /> REPAIR/ADDITION(Prev. Sanitationir Permit# -------7--.............................. Date ....................... <br /> Septic Tank (Specify Requirements) ----I—,.................. .... ............................................ ....... .................. <br /> - ----- ------ <br /> Disposal Field (Specify Requiir ments) <br /> ------------------------------------------------------------------------------- ........................................... ......................... . <br /> Jb <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 J"461n, <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local HeaI&DIshict. Nome owimw or IICO,n- <br /> zed agents signature certifies the following: <br /> "I certify that in the periormance"of the work for which this permit is Issued, I shall not employ a' 6y person In such manner <br /> as to become subjert to Workman's-Compensation laws of Califernicii.- <br /> Signed <br /> ---- -- ---- ----------------------------------------------- Owner <br /> By ..... &2 <br /> -- - ---- --- ------------------------- -------------- ........ <br /> ---------- . ..... ...... . . <br /> 44o <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> -------------------------- ------- -­­--------------------DATE <br /> BUILDINGPERMIT ISSUED -------- --------------------•--•--------..._------.....---- ----­-------_--------- -----DATE ........................................ <br /> ADDITIONAL COMMENTS --------------- <br /> ----------- ......................................... <br /> ...­........................................ <br /> -------------------- -------------- .... . ....... ----------N_ --------- ------- ----------------------------- --------------------------•---..-...... <br /> ---------1--...... <br /> ---------- ------ - ---------------------------------- ------- ...............&------------------------- .................... <br /> Final Inspection by: - -- -- --- ---1- �----------- -.._--.---........----_....--•.................. ..............Date Ap­ -_1............... <br /> EH 13 211 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />