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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------- Permit No. <br /> (Complete In Triplicatell <br /> ....... . .... <br /> ........... This Permit Expires I Year from Date Issued Doti <br /> Application is hereby mods to the San Joaquin Local Health District for a permit to construct and Install the work heroin <br /> described. this application Is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC 53q 3 <br /> .... ....... <br /> ATIOq <br /> ........L,.- ...... ....... .................XENSUS TRACT ........ <br /> S . 4. , <br /> Owner's Name .............. . <br /> Address ­_...Wfa-ZFZ.....I——....... City — <br /> Contractor's Name.... X"I. <br /> ..... ...............License #&1*3113... Phone YU.._..f4A7.... <br /> Installation will serve: Residence <br /> ( Apartment House-f] Commercial OTrallor Court 0 <br /> Motel []Other........................... ................ <br /> Number of living units-��(_.A, Number of bedrooms .....�I`Garb <br /> age Grinder ....... Lot Size ................... <br /> Water Supply. Public System and name ......................................t............. ....... ...Private 0 <br /> Character of soil to a depth of 3 feet- Sand 0 Silt 0 Clay C1 Peat 0 Sandy Loom 0 Clay Loam 0 <br /> Hardpan o . . Adobe""Fill M6terIal_ Af <br /> ............I yes,type ..,........... .......... <br /> (Plot pldn,-showing size of lot location of system In relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALVAXJO � JNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT Ca f SEPTIC TA14K f Size................................... -_-------- Liquid Depth ........................ <br /> ------------...... Material.................... No-. Compartments. ...................... <br /> �`;-y-^.-y- :]�T e,� `s <br /> V <br /> Distance,to nearest: Well ....................................Foundation ...................... Prop, Line .............I......... <br /> LEACHING LINE No. of.Lines ........................ Length of each line.._..............:_._....... Total .Length ......... ................... <br /> V Box ...... Type Filter Material ..Depth Filter-Material ............................................ <br /> Distance to nearest: We'll ........... ............ Foundation .................. Property Line ........................ .0 <br /> SEEPAGE PIT Depth ..................... Diameter ................. Number ............................ Rock Filled Yes E] No .C3 <br /> Water table Depth ............. ...I..........­.................Rock Size ... ............................. <br /> Distance to nearest. Well ...................................Foundation .................... Prop. Line <br /> REPAIR/ADDITION.(Prov. Sanitation Permit ` ........................... .............--- Date ...i......... .......... <br /> Septic Tank {Specify Requirements) ......... -------------------- .................................................................. ........... ............... <br /> r <br /> Disposal Field (Specify -Requirements) .. ......6 .. .............. <br /> , G_ - I ------­--­----- --------------- <br /> .........................­ 1, X �_ I ...0 1..-LVI...... ..................... ....... ............... <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 don* In accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the -Son Joaquin Loical Health'District. Home owner or licen. <br /> sed agents signature codifies the following: <br /> "I certify that In the performance of the work for which this permit Is issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---•----=-•----.-:_..:-- ------_-----------------__ Owner <br /> J <br /> BY ---------- <br /> ...... .. I------ - ­- ------- .4?. -----------------------------•----- Title ........... ... ............... ............ <br /> {if othern owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ------------ -- - -------•----- --,;------------------------ ...... DATE 7 <br /> BUILDINGPERMIT ISSUED ........"_+-------------- ------------ ----- ..................................... ..............DATE ......................... <br /> ADDITIONAL COMMENTS ----- ....... ...............I.................. <br /> ---------------*------------------------------------ -----------------------------------------7------------ ------------------- -------------- --- ------------------------------------- <br /> ---------------­1------------------- --------- ------ <br /> ------- - ­---- --------------- .:_..-----------•-•---._.......---:---........ ----•-.. ............... ...........I................ ....... <br /> ................... .. --- ------- ............ --------I..••-- .•-----... <br /> Final Inspection by: --- -----------­ ----- .... -----------•••. .. ....... .........Date .. ..... <br /> . �7 <br /> EH 13 241-68 Rev. 5M <br /> SAN. JOA UIN LOCAL ALT DISTRICT 8/7h 3M <br />