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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -75- <br /> ..................................4................... <br /> Permit No. ........ <br /> (Complete In Triplicate) <br />. ..........I................ ........................... <br /> .................... ................... This Permit Expires I Year from Date Issu <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to cansmid and Install the work herein <br /> described. This application is made in comAiance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .... .. ........... ..........................................CENSUS TRACT .......................... <br /> Owner's Name .. ..... 4t-'-----•......r <br /> ------ -PhWJ <br /> Address ................... .. ...... ................city .......L--ta one!. <br /> ............. <br /> Contractor's Name ----------- -- ....... .. .. ....ie....... .........................License Phone, ...64 <br /> Installation will serve: Residence[3 Apartment House 0 Commercial OTraller Court 0 1 <br /> Motel 0 Other ....... <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ...... --------------- <br /> Water Supply, Public System and name ---- .................................................. <br /> -Z_,:� Private 0. <br /> ---Ize <br /> Character of soil to a depth of 3 feet: Sand t3 Slit 0 Clay 0 Peat 0 Sandy Loam 0 Clay Loom 13 <br /> Hardpan 0. Adobe 0 Fill M6terlal ............If yes,type....... <br /> ..................... <br /> {Plot plan, showing size of lot, location of system In relation to wells,buildings, etc, must be./placed an reverse side.) <br /> NEW INSTALLATION: (No septic tank or.seepaged sewer y t . . <br /> .pitpermltte if,publiis available within 200 feet) <br /> PACKAGE TREATMENT -SEPTIC TANK[ ] size......... LI <br /> ................................ ..� &ld Depth ...................... <br /> Capacity ------------------_ Type a.. m ...... ---------- -- <br /> ................_ Material........z.............. N rtm <br /> _0o ents P <br /> Distance.to nearest: Well ............................ -......Foundation�I......2_� Pir6p.1 Line ...................... <br /> LEACHING NE No. of Lines ...... ................. Length of each llne`_I_�........ ....... Ta't6li Length' ..................... <br /> V Box Type Filter Material -.......... Depth f€Iter Material <br /> ........................ ................... <br /> Well ......... <br /> Distance-to n ...... Foundation, Property Line ........................ <br /> SEEPAGE PIT <br /> Depth ------- Diameter ----- ----------- Number ............ <br /> ...... R&k Filled Yes 0 No 010 <br /> Water Table Depth .......... fl��............ <br /> ................Rock'Size 0 <br /> Distance to nearest: Well ...... ................... <br /> ......... .Foundation Prop. Une .... .................. <br /> REPAIR/AD[,ITION(Prev. Sanitation Permit# ........ ................ Dt................... I ............ ............ <br /> Septic Tonk4Specify,,Requirements).............. <br /> - ..k.... <br /> ...... ............ .......... ............. <br /> ............ ...... ------------- <br /> Disposal Field (Specify Requirementsi - --- --- ............. <br /> I.:..............f...... .......... ....... <br /> --------------- -------------------­­1------------------ ......I­------­---------- ........ if <br /> ....................... ............................ ............... ........... <br /> (Draw existing and required addition on reverse si8i)- <br /> ' <br /> I -hereby certify that I have prepared this application and that the work vMl.be done irk-lacccirdance with Son' Joaquin N1 1 111 <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin,Local Health.Disirict.:Home owner or 11con• <br /> sed agents signature certifies the following: <br /> "I certify that In the performance of the work for which this permit Is Issued, I?sholl net employ any person In such'manner <br /> as to become subject to Workman's Compensation laws of California.- <br /> Signed ---- ------- -------- ---- --------- ......... ......................................... Owner <br /> By ..................... ------- <br /> -------- -----------• -------_---- ........ --- Title -­--------- ....... -------------- <br /> (if of than owner) i <br /> FO"150ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ........................... ...... DATE t. .................................... <br /> BUILDING PERMIT ISSUED <br /> ......... ... ------- --V. __DATE ...............­............... <br /> -7- . <br /> ADDITIONAL COMMENTS --- --- ------ -- ----- <br /> ­­--------- ............ ........I...... <br /> -------------------------------------- I t_ --- <br /> - -----------­11------------_ -­ -- ----- <br /> ------- 4rV...... . ... .......I....... ----- - <br /> .... ................................ .... <br /> ----------- ------------------- ............. ------- ­--------------1... ....... ............ --------------- ----------------r--------------- <br /> -----------I--------- ------------------------------------------------­ - <br /> ------------------- *-------- -------- -------- ----------- ----- <br /> ----- - .. .............. ......... ...............I....................._...............Date ..................... <br /> Final Inspection by: --------- - ------- <br /> EH 13 2h 1-68 Rev- 5M SAN JOAQUIN LOCAU"HEALTH 0ISTRId_ '__'__ 8/74 3M <br /> P-4 <br />