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>' FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ............­­­-------- ....... ........ <br /> Permit No.Z�.............. <br /> (Complete in Triplicate) <br /> ...........I.......... ........... ............... <br /> 4A.rl ........ <br /> ........­­................ ......... ...... This.Permit Expires I Year From Date Issued Doti Issued _1.1 <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 ......... ........ .................•.........CENSUS TRACT ................ <br /> Owner's Name .............. .....................:................Phone <br /> Address ........ -a. ... ------I <br /> --------- ............. ......city <br /> "Z ........... ------------­----r............................................ <br /> Contractor's Name . ......... ........�ment <br /> ------------- ........ .............License # ........................ Phone .................. <br /> Installation will serve: Residence House f:] Commerclal'oTraller Court 0 <br /> Motel 0 Other............................................ <br /> Number of living units ---- Number of bedrooms L/......Garbqge,'!�Incler .......1_... tot Size ....... ZAV ......... <br /> Water Supply: Public System and name -----_----- .......­.................­....... <br /> .................................................. <br /> ­.-PrIVU to [3 <br /> Character of soil to a depth of 3 feet: Sand 1] Silt[] Clay 0 0 Peat Sandy Loom m—'Clay Loom <br /> Hardpan 0 ; Adobe 0 Fill M6terlal..L........... it yes,type ...._1........ ........ <br /> Mot plan, showing size of lot, location of system In relation ter wells, -buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION. (No septic tank or seepa- pit permitteclAtpybfic sewer Is available within 200 feet,] <br /> PACKAGE TREATMENT SEPTIC TANK J-r Size........:1................. ...... ........... Uquid Depth .......... ............... <br /> Co <br /> mpartments ........ ............ <br /> Capacity ...1�0.._ TypeNo. <br /> Distance to nearest: Well ......�.c!....=oundation ...... Prop. Line.--.-/L&2.... <br /> LEACHING LINE I q`_'No. of lines -------I-._..__ Length of 6_06-41ne......2' ... Tofal.' 'Length ..q2.0................ <br /> At . ..... <br /> V Box Iter Material .Filter,PX ...... Type F! ep er Matorlal;­.. ... ........................ <br /> Distance to nearest; Well ......Foundation ...wl.��........ Pro'� <br /> perty ilne'.Ar .......... <br /> SEEPAGE PIT Depth .................... Diameter ......... ..... Number ......................__ Rock Filled Yes t3 No (:33 <br /> Water Table Depth .......... ............................... ..---Rock Size ......................... <br /> . 'Distance to nearest. Well ---_-------1_...... ..................Foundation .................. <br /> Prop. Line .. ................... <br /> REPAIR ADDITION(Prev. Sanitation Permit# .......... ........................... Date .......... ...........I <br /> Septic Tank (Specify Requirements)............................... ...... <br /> ----------------------------------------_,•-------- ---------------- ---------••----- <br /> Disposal <br /> ...............Disposal Field {Specify'cify Requirements) ......... <br /> ....... ............................. .................................................. ...... ............................ <br /> -------------------_......•---- -----------------------------*----------------------- ------------------------------- ................­­__ <br /> ._L___________________________ - .. ---- ------------ ....... -------­----- ................. . ....... ............................ .......... <br /> {Draw existing and required addifl6n—on.revprii side) <br /> I hereby certify that I have prepared this applic6tion and that the work will-'be done in 't ccoirclance with San Joacl4ln <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health-District. Home owner or Ikon- <br /> sed agents signature codifies the following: <br /> "I certify that in the performance of the work fair-which-IMs-perWt-is.liamed,-I-ShollL=not employ any.person in such mannor <br /> as to become .sublect to WowrkKm in'$, mpen sP_Ion laws of Calill"T Ia." <br /> Signed ......... .. r.. <br /> By .... ------------------------------------------------------- ............................. Title .......................................... ........ ...... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- i -----••••----•••-••-----_... ---•------------------0_,DATE _77 <br /> BUILDINGPERMIT ISSUED ------------- ------- ............................................ ----------------------------_DATE ...........------.._...._.._.._:....._--••" <br /> ADDITIONAL. COMMENTS .................................... ------------------ ---------;.................. --------------------*----------------------------- <br /> ----­---------------- • <br /> -------------------------------------- ------------------------------------------------------------ ------­ ­-. . <br /> ------------------------ <br /> .............................. -------- ------------ <br /> --------------­ <br /> .............. .........­....................... ---------------.-.-.-.-.-.-------------------*------------------------------------------------------------------I----- <br /> Final Inspection by: __............... D----a----t--e-----------_--------?-------------­ .-.-.-.- <br /> .-.-.-.--..-." ....... ....... 7-- c.. ....-.-...-...-.-.-..-..-..._. <br /> . <br /> EH <br /> 13 2L 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 8/7h 3M <br />