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FOR OFFICE USE.AM <br /> APPLICATION N FOR SANITATION PERMIT <br /> Permit <br /> (Comphite In Triplicate) .............. <br /> .................. <br /> Date Issued -_--- <br /> __.................... This Permit Expires I 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 /> RACT .......................... <br /> JOB ADDRESS/LOCATION ...CENSUS,T <br /> Owner's Name ....... .........ae's: �/------------------------------------.. ..........:.........Phone <br /> ............................ <br /> Address,._-. + ./------- <br /> % --------_--------_----- city <br /> Contractor's Name ..... <br /> . .........License Phone 4.%6 <br /> Installation will serve: Residence Apartment House 0 Commercial OTraller Court 0 <br /> Motel 0 Other .......... <br /> ........................ . . <br /> Numbir of li;Ong units:---I..... Number of bedrooms .'Z—.__G*rbage Grinder Lot ...... <br /> Water Supply: Public System and name2".-4.0.j 0 .................................................... <br /> ............ ............................L..Private 0 XJ <br /> Choracterof soil to a depth of 3 feet: Sand r] Slit Clay 0 Peat 0 Sandy Loom 0 Clay Loom El <br /> -Hardpan 0 Adobeo Fill Material ............ Ifyes,type ...' <br /> .......... ........... <br /> (Plot plan, showing size of lot, location of system In,jelation 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 f SEPTIC TANK I I Size______--__-_ - Liquid Depth .............. <br /> Capacity ----------- ........ Type ..... ........ Material-------- --- --- -•. No. Compartments ...................... <br /> Distance to nearest: Well ------- ........... ................iFounclotion ..........-----•-•- -. Prop.1"Llne. ...................... <br /> LEACHING LINE No. of Lines _-__-..1.___-..__-__.... Length of each line.._....4-42............ Total Length ....Q .....I......... <br /> D' Box .Cc�... Type Filter Material,.A/9.X./_.e,.Depth Filter Material. ......... ........... <br /> Distance to nearest: Well <br /> ..-Foundation -../10_`'.-___.-y. Property Line :...;5............ <br /> SEEPAGE PIT Depth ---c;,?.S......." D!b66tbf=,.43._._Njm er __...._:,C._-._..7'....._.. Rack Filled Yea'&�l <br /> Water Table Depth --------4aps ........ -----------------------Rack Size <br /> Distance to nearest.. Well ...... . ----_------ ....Foundation Prop. Line ............P_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .........-.................L__.......... Dote --.-r-----:----•--..__............}.............................. <br /> Septic Tank (Specify Requirements) _......... <br /> ....................... ................... ....... ............ <br /> . - r < 49 a ,*------2*,*,- 1 <br /> Disposal Field (Specify Requirements) --------A-a�....... 9451. 4::�.. ------- ............................... <br /> 16 . ........... <br /> ---------L�22-----X.A* .. --- - <br /> ---- <br /> -----------------------------1 41 <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.6e done In accordance 'with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health;District. Home owner or licen- <br /> sed agents signatuie certifies the following: <br /> "I certify that In the performance of the.work far which this permit is Issued, I-shall-.not-employ any-person In such manner <br /> as to become ect to Workman's Compensation laws-of California." <br /> 7,e ec�to Workman's <br /> Signed -------- - ----- -- --- --- --- ......;24-tk.................... Owner <br /> By ---- ---------_---------- <br /> ...... -------------------- Title ................... <br /> (if er than owner) <br /> R DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY ----------- ---- - ------- ---- <br /> ­ <br /> ---------------- ----------- ------------------ --------------- DATE ........... <br /> BUILDING PERMIT ISSUED . . ..... - -------_------- - --------­--------------------------- --------- DATE ......... ------------_ ....... <br /> ADDITIONAL COMMENTS ------&-Al------ .... ......... ....... ----------------------•--..._......__.- <br /> ------------*-------------------------------- ------------------------------------- ................... ..................­.­................................ .......................... ----------- <br /> -------------- --------------------------------- <br /> -------- ---------------- -- ------------------------------------------ ------- -------------------------- ----------------------- <br /> ---------------------------------*----------- . . ..... - -------------------- ........­­------------------------------------I.......... <br /> Final Inspection by: ...................... ------------------ -------------------------------------------------------- <br /> ---------- <br /> EH 13 24 1-68 Rev. 5M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />