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FO ICE USE <br /> APPLICATION FOR SANITATION PERMIT /7 <br /> (Complete in Triplicate) w. <br /> Permit No <br /> .. ...... .. ......... ....... <br /> Date Issued <br /> ------------------- ----- - ------------------------------ This-permit Expires 1 Year From Date 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 with County Ordinance No. 549 and existing Rules and Regulations.. <br /> JOB ADDRESS/LOCATION ---?__/--- ---------- --------- --- - ---41-------- ------------ -- -------CENSUS TRACT ------ - ------------ <br /> Owner's Name ------ Ah)kpo_5�. ----- ---- <br /> - ------ ---- ---- -_ -- ------- -------------------Phone ------------- <br /> Address ------------------ ---- ------ itV <br /> ----------------------------- ity ------------------------ ---------------------------------------------- <br /> Contractor's Name -------------------- ------ License # --------- --- ---------- Phone ---------- - ------ <br /> Installation - <br /> will serve- Residence t-epartment House f� Commercial �[]Trailer Court T� <br /> MotelEl Other ------------ --------------------------_- <br /> Number of living units-- - ------- Number of bedrooms -_--__Garbage Grinder, Lot Size ---------- <br /> Water Supply: Public , em and name ------- —------------ <br /> ----------- - - ----------------------------------------- Private <br /> Character of soil to a depth of 3 feet: Sand'FSi It Clay EPeat ESandy Loam Clay Loam <br /> Hardpan E] Adobe X Fill Material ------------ 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 seepa pit permitted if public sewer it availab!p N) hin 200 feet,) , <br /> PACKAGE TREATMENT SEPTIC_tANK'k _'6-_-_-Liquid Depth ------ <br /> 0i 7 <br /> Capacity Typ _r�e,Materk _C------- No. Compartments ------------ <br /> t-^ 11 f If <br /> Di ante to nearest: Well ------------- ________________Foundation . -_____-__,Prop. Line _______r1-_.__..._.._ <br /> LEACHING LINE /ZNo. es --------- I ?_/----------- <br /> of Lin ---- Length each line-___- ------------ Total Length <br /> `D' Box Type Filter Material ---6,4A-------Depth Filter Material ---- ------- --------- <br /> Distance to nearest. Well ---5'9........../_ Foundation ____/Q_____________-------------- Property Lirie -------- <br /> SEEPAGE PIT L/-�Depth ----Id Dia44;jaer - ------ Number ------- Rock Filled YesNo c <br /> 4)---------- <br /> u IM Water Table Depth ------------�_O_ ---------------..Rock Size CIOW,�lv------------------- <br /> Distance to nearest: Well --------- /--d----------- Prop Line _._.___ --f...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> SepticTank (Specify Requirements) -------- --------------------------------------------------------------------------------------------------- ----------------------------- <br /> D)s IN <br /> _)?osal Fie�l (Specify- Requirements - ------- ----- --------- ------- --------- -=-------- <br /> Y. I--------- <br /> ------------ -- <br /> ._614-V <br /> ------------- <br /> ------------- - --- --- -- <br /> --- -- --- -- ----------------------------------------------------------------------------------------------- ---- - --------------------- <br /> �?aw Kis inag and required addition on reverse side) <br /> A�K ( xis I <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.District. 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 manner <br /> as to become subject to Workman's Comp I riscition laws of California." <br /> Signed.-te---- --------------- ------------------------- Owner <br /> By ------------------------------------------------------------------- ----- ----------------------------- Title ---------- -------------------------- - ------------------------------- <br /> (if other than owner) <br /> YMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- -- <br /> - - <br /> - - ----- ------------------------------------------------- DATE ---------- <br /> BUILDING PERMIT ISSUED ---------- --- <br /> - - ------- ----------------- <br /> ------------------------------------DATE -------------------------------- ---------- <br /> ADDITIONAL COMMENTS --------- -- - -- --- -------- - ------ ----- ----------------------------------- <br /> --------------------- ------------------------------- ------ ---- -------- ---- ------------------------------------------------------------------------------------- ------------------- --------- <br /> ------------------------------------------- - - ----------- ------ -- --- ----------------- <br /> ------------------------------------------- <br /> ----------------------------------------------------------- - ------ - ------------- - ------------------------------------------------------------------- -- <br /> Final Inspection byc------- -- ------ Da---------D­�_�r .7--------------------- <br /> ---------------------------------------------------------------- ------ --- <br /> JO UIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev- 5M <br />