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FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT <br /> Permit.No. . .................. <br /> ............... ................................ icomplete in Triplicate) <br /> .........1----------- Date issued <br /> This Permit Expires I Year From Date Issued <br /> ................­4.......... ........ <br /> made to the Son Joaquin Local Health District for a permit to constr�d and install the work herein <br /> Application is hereby xisting Rules and Regulations. <br /> described. This application is made in compliance w.1th County Ordinance No. 549 and a <br /> JOB ADDRESS/LOCATION . ................ ......................CENSUS TRACT ..................... <br /> /. ..........Phone .............................. <br /> '7- <br /> ............ ........ ............... ............ <br /> ---40-�- <br /> Owner's Name <br /> Address ........... ... .. .......city 3 <br /> �10 ....License # . 2- ......................... <br /> Phone .... <br /> Contractor's Nome ----- ...... ..* <br /> Installation will serve: Residence portment House 0 Commercial OTraller Court 0 <br /> Motel 0 Other ........................................... <br /> .......... <br /> Number of living units:.....L--,- Number of bedrooms -&-3.....Garbo ge Grinder ......... Lot Size ....... <br /> Water Supply. Public System and name ---------.............--................. .........I.............................. ..............Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 <br /> Clay 0 Peat El Sandy Loom lay Loom [3 <br /> Hardpan C] Adobe 0 Fill Material ............ If Yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system In relation to--wel I-s-,-tyu lid lrvgg,- 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 I I Size------------------ ....................... ..... Liquid Depth ......................... <br /> . <br /> Capacity ----------- -------- Type -------------------- Material --------------. No. Compartments ...... .............. <br /> Distance to nearest. Well ..............................Foundation ...................... Prop, Line .... ................. <br /> ............................ <br /> LEACHING LINE No. of Lines ..------------ --------- Length of each line........... ..........--... Total Length <br /> 41 1 I ...w<�...........:.Depth-Filter Material ............................................ <br /> *D' Bbx ------ ----- Type Filter Materia <br /> 0 1 <br /> Distance to nearest:-Well--.--.- ..... Foundation ............-,-. Property Line ........................ <br /> 0- <br /> SEEPAGE PIT DeIA --------------- Diameter. ........ Number ------------ --------------- <br /> Rock Filled Yes El NO <br /> Wdt,er Table Depth '`----------------------- ........................Rock Size ------------------ ............ <br /> Distance to nearest- Well ...............-......................Foundation -------------------- Prop. Line .................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit ---•-•-•.-•-----•-••------------•---------__ Date -------- <br /> ... <br /> ....... ......... ........ <br /> ................... --------- ....... ....................... <br /> Septic Tank (Specify Requirements) <br /> ............................•------- ............. <br /> Diall.�Frielldd (Specify' Requirerients) <br /> .. . . ......... -------------- -- --------- .......... ------------- ------- --------- --- <br /> ------ ---------------- <br /> .................. <br /> --------- - - - ------------- ---- <br /> ----------------------------------------I ------(-Draw-existing­a`n-d--required-addition--o-n..reverse 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 Laws, and Rules and Regulations of the San Joaquin Local Health,,DIstdc.t. 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 Mann.or <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .........----- - ------------------- Owner <br /> q)--------; ....... .... -................ <br /> By -------------------- -------- - ` ------ Jitle --- - --- <br /> (if other-. - - thanownerl <br /> C-( <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------ DATE <br /> BUILDING' PERMIT ISSUED -------------------------------I--------------- ------- ------- -------------- .........-...DATE ..,.._--------_------.------•----- ------ <br /> ADDITIONALCOMMENTS ----- ------------- ------------------------------------------------ .....................................-.......... <br /> .................. .---------I-----------1--------------------------------- ------------------------------------------------ ...................---....... ------------------------------------- <br /> ------------------- ......... .. ---------- ............. .. <br /> ----------------- --------------------- -------------- ------------------- ------ ......... <br /> -------------------- -----W- <br /> ------------------------------------ ---------------------- <br /> --------------I---------------------------------- ---------------------- --*.... <br /> Final Inspection by: ----------------------- ....v......... ...... ----------------------------------- ------Date <br /> EH 13 2h 1-68 Rev. 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />