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FOR OFFICE USE: <br /> z" -------�,I�-------- APPLICATION FOR SANITATION PERMIT Permit No.. <br /> —------- (Complete in Triplicate) Date Issued <br /> ----- --------------------------------------------------- This Permit Expires I Year From Date Issued <br /> Application 1-s hereby made to the Scn,Joa'quin Local Health District for a per'mit to construct and install the work herein <br /> described. This application is made in cogliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ....................................... TRACT ----- -------- <br /> JOB ADDRESS/LOC I . . . . . . . . ............... CENSUS <br /> #1 ---Phone ------------------------------------ <br /> Owner's Name --- --- -- - ---- - --- -- ---------------------------------------- <br /> prd-� ity���� <br /> Address /6-yo --- - -------------------------- ------- C ------------------------------------------ <br /> Contractor's Name - ------ A-� --------.License V,./.4/ 3/s/Z., <br /> ------------- -- ense # --- Phone . ............ <br /> Installation will serve: Residence F] Apartment House�E] Commercial frailer Court <br /> Motel.F)Other ------ ------------------- <br /> Number of living units:__.-___.__ Number of jaqd 0 msd�------ -G rbage Gr' der -- --------- Lot Size ---------- <br /> c'-ro M_- <br /> *ilt 0 Clay 0 Peat E] Sandy Loam Ej Clay Loam El <br /> * po, 1� - <br /> Water Supply: Public System and name ------------- ------- -------------------------------------Private <br /> Character of soil to a depth of 3 feet: -Sanqd'El <br /> Hardpan E] Aclobex 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 seepage pit permitted i!,,Public sewer is available within 200 feet,) <br /> .el;, <br /> PACKAGE TREATMENT SEPTIC TANK` Size-------- .................... Liquid Depth ---------------- <br /> Capacity/O�AO------- Type P1W_& _ Material ------- No. Compartments ------t .......­ S\ <br /> Distance to nearest: Well _ 0XV_ ________________Foundation; _AZ>_*------------- Prop. Line ------5------7------ A <br /> LEACHING LINE X' No. of Lines ____-___-/__________ Length of ea line-./ 0____________ Total Length __/0Q.........._.. <br /> 'D' Box ------------ Type Filter Material____ _- _c-tf"Depth Filter Material ---I-e-"* o----------------- ......... " <br /> Distance to nearest: Well Foundation __140............. Property Line ---s---------- ......... <br /> SEEPAGE PIT IV Depth 1:2-7-e--- ___ Diameter 7_47-------- Number ----------- -----ot---- Rock Filled Yes No <br /> Water Table Depth -----4-40-- <br /> - -------------------------------Rock Size _jo� ------ <br /> ----- <br /> Distance to nearest: Well --- O-LA-00_________________Foundation ----- -- --- Prop- Line ---- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------..---•----------) <br /> Septic <br /> ------------- -------- ---------- <br /> SepticTank (Specify Requirements) --- ----------------------------------------------------------------------------------------------------------------------------------------- <br /> Disposal <br /> ---------------------_-_---------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 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 p r�m 5Tcie of the work for which this permit is issued, I shall not employ any person in such manner <br /> t: or <br /> a <br /> as to be me Isbieft ork. . in Ts Compe 4sation laws of California." <br /> ,�,.to an.Cc <br /> Signed -------- Owner <br /> BY -------------- -------- ------------ ---- <br /> (if other than owner) ----------------- <br /> - Title ---------- ------------------------------------------------------------- <br /> (T1 <br /> PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------ ----- --------------------------------------- - <br /> ---------------. DATE ----------------- <br /> BUILDINGPERMIT ISSUED ------ ---- - --------------------------------- ---------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------ ------------------ ------ ---------------I------------------------------------------------------------------- <br /> - ----- <br /> --- - --- <br /> A61 ------- - ----------------------------------------------------- -------------------------- <br /> - <br /> -------------------------- ------------------ - -------------------------------------------------------------------------------------------------------------------- -------------- <br /> Final Inspection by- --------- ) <br /> - 4 ------ <br /> JOA QU I N LOCAL HEALTH DIS TRICT <br /> E. H. 9 1-'68 Rev. 5M <br />