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FOR OFFICE USE: <br /> MOPLICATION FOR SANITATION PERMIT <br /> ------- -68--------3!o (Complete in Triplicate) Permit No, <br /> - -- ------------------- <br /> --- ----------- ---------------------- ;his Permit Expires I Year From Dot.a Issued Date Issued <br /> -4_ <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to constructandinstall the work herein VN <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> e::Pl 3 <br /> JOB "ADDRESS/LOCATION ---- ----- CENSUS TRACT <br /> f '2 <br /> Owner's Name --------------- ------ <br /> -- --------------------------- ---------- <br /> -- - -------- <br /> ---- ------------ ------------------------------------- -------- ---- ----- --------------Phone --- <br /> Address ----- ------------------------- <br /> ----------- ------- <br /> -I, --Z 3--0-------------------------------------------_. City <br /> Contractor's Name - ------, - ----- --------- - --------------------------- <br /> -- - ------- -------------------------------------------------------------------License -i/ <br /> n"L5-- Phone <br /> Insto s Ilation will serve: Residence 'House,E] Commercial'OTrailer Court <br /> Motel E-]Other <br /> Number-of-I-i v i ng--un its Number-of-bedrooms <br /> i ---: -3------Garbage-Grinder" Lot Size <br /> Water Supply: Public System and name ------------ ------------------------------------------------------------------- ------------------Private <br /> Character of soil to a depth of 3 feet: Sand Clay [D' Peat El Sandy Loam ,[] 'Clay.Loam F� <br /> `11�! ❑S ,I , <br /> 99 <br /> _HarclpamED L-Aclobe <br /> ------ 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 if publicl sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f I SEPTIC TANK f Size----------------------- ----------- --------- Liquid Depth <br /> I - - ------------------ <br /> Capacity Type J Compartments 9.-----------­ <br /> Distance to nearest: Well -------- f I <br /> LEACHING LINE No. of Lines 12— --------------------Foundation __LP--------------- Prop. Line ............ . <br /> ------------------ Length of each line_1_71_�------------- ------ Total Length _44171 / <br /> 'D' Box ---'(------ Type Filter Material icC_A�-------Depth It 1,Filter Material ----4- ---- <br /> " -----I--------- <br /> ----------- -- ........ <br /> Distance to nearest: Well ---77= 'on <br /> � — r -------------- Founclat! 4� -------------- Property Line ------- <br /> SEEPAGE PIT Depth 33 <br /> ----------- Diameter <br /> ---- Number!------- ------------------ Rock Filled Yes Ej­ No �C] <br /> Water-Table.-Depth- - I I . <br /> Distance to nearest: Well Si-zie -----------------:-------------- <br /> --------------------------------------- Foundation -------------------- Prop. Line .-----•----------•--•• <br /> REPA'lR/ADDIflON(Prev. Sanitation Permit c# -------------------------------------------- Date--'J <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify Requirements) <br /> ------------------------------------------------------------------------------- <br /> - -------------------------------------------------------------------------------------------------------------- <br /> -------- --- ------ ----------------------------------------------------------- <br /> -- <br /> ------------ - ---t------------------------------------------------------------------------------------ <br /> (Draw existing and required addition-_6nreverse_side)----------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the. Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies 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 Comp nsatilaws of California." <br /> Signed ------------------------- <br /> --------------------------- Owner <br /> By ---f------------------------------------------------------------------------- Title(if other than owner) <br /> ---------------------------------- ------------------ <br /> F RDEPARTMINT USE <br /> ONLY <br /> APPLICATION ACCEPTED BY /04/74� <br /> ........ . <br /> ........... <br /> BUILDING PERMIT ISSUED ----- -------- DATE _ <br /> ADDITIONAL COMMENTS -----------------------------------------DATE ------------------- ----------------------- <br /> !-------------------- -------- ---------------------------------- <br /> ----------------------------------------------- ------------------ <br /> �J------ -----------------7---------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------ ------------------------------------ <br /> -------------------------------------------------------------------- <br /> FinalInspection by: -------- ---------------------------------------- ----------- -------------------------- <br /> --------------------------------------------- -----------------------------Date0 <br /> ---------- ----------;;,;,----------- <br /> ------ ----------- <br /> __-_SAR..J=QAQUIN_'LO 7 CAL" HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />