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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -7 -------------- -- Permit No/a:1�� - (Complete in Triplicate) ---------- - -------------------------------- I Date Issued ------------------------------------------------------- This Permit Exp ires 1 Year From Date Issued Application is hereby made tot he lan Ja ouin Local Health District for a permit to construct and install the work herein q described. This application is made in compliance with County Ordinance No. 549 a existing Rules and Regulations: ENSUS TRACT ------------------ JOB ADDRESSAOCATION /-!__C_- ------ [ ---,- ) -------- f Owner's Name -- -------_--- C-ir1YL �/ Phone - ------ Address ----------------- = -------------._.. City _ 2{,qq�P _ Contractor's Name-. _..___- -------.License #2-�/_ot,_1__ Phone _ __Installation will serve: ResidenceIg Apart n House❑ Commercial []Trailer Court ,❑ Motel ❑ Other -------------------------------------------- Number ------------- ---------------------------Number of living units----------- Number of bedrooms __Nr$----Garbage Grinder ------------ Lot Size �u �1� Water Supply: Public System and name -------------------------------------------------------------------------- ---------------------------• ------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay ❑ Peat❑ Sandy Loam ,X Clay Loam ❑ Hardpan ❑ Adobe .❑ Fill Material -_----- .... If yes,type _________---------------" -- . I (Plot plan, showing size of lot, location of system in relation to, wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is av ' able within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] t Size__- _ ___Z/__-/4-_--��-_ - -- Liquid Depth __— -3___..____,_.: � Ca acifi U'a a� No. ==:.... I P Y / TYPe�' uCompartments r v Distance to nearest: Well -7a.,..---------------Foundation .../--_______-___ Prop. Line 119__ 4, �� ' N, LEACHING LINE [ j No. of Lines -------- -------- Length of each line____-/ Q-------------- Total Leengthf ,-�_�d_________:.. 'D' Box ----/----- Type Filter Material _�_ __.Depth Filter Material __f_e-_________________________________ O Distance to nearest: Well -------- Foundation ---------- Property Line ...... ............ �] SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No .o WaterTable Depth -----------------------------•- ---------.------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- 1" REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date _______-__._______-.--------------I SepticTank (Specify Requirements) --------- --------------------------------------------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------ ------------------------------------ --------------------------------------------------- - - ----------------------------------------------------------------------------------------------------------------------------------------- f (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----- - -- -- -- - ----- -- ------------------------- Owner - 1 r BY ------- 'Z�� _ -------- Title ------------------------------------------ ---------------------------- {If other an owner} FOR .DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY _ ------ -- ----- ------ DATE r�--`----- BUILDING PERMIT ISSUED ------ --------------------------------- __DATE _.---- ------------------- ADDITIONAL COMMENTS - -------------------------------- ----------------- ------•- ------•---------------- ------------------------------------------------------ ----- -- ' ------------------------- ::-::-- ------- --------- -- ---------------- ------------------------------------------------------------------------------- ----- - ;� Final Inspection by-- ------- ---- ---------------------------------------------------------------------.Date _..- =��_-, �—.-- SANAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M