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�;,FOA OFFICE USE. APPLICATION FOR SANITATION pEkrMT <br /> . ................ .. <br /> ......... .. . .....I...................."............ <br /> (Compleft In Triplicate) Permit No. ............... <br /> ..m . . ......... <br /> ........... •......................................... This Permit Expires I year From DOM Issued Doti issued .Z................ <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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulationss <br /> JOB,ADDRESS/LOCA ON <br /> . . ....... ..... .......P..............................CgN sus TRACT ................... ...... <br /> Owner's Name .. <br /> Y.......................... ........... ........ ......Phone ............................. ...... <br /> ... . . <br /> .............. <br /> . .. ............. <br /> Address ...... .. &-9. 4 42 <br /> ..... .. .........city .. .... . <br /> .. . .... ....... ........................ <br /> Contfactof's NameF. <br /> .......... ..... .......1.1cons'a# . ................. <br /> Installation will serve: Residence j!rAportm <br /> *AtHoussO Commercial OTraller Court O cupy <br /> Motel 0 Other................;................. <br /> Number of Jiving units ....... Number of bedrooms ....2�:.Garbage Grinder ..... ...... Lot Size <br /> ....................................... <br /> Water Supply: PublIcSystem and name ...... ....................................... <br /> Charader of soli to a depth of 3 feet. ..................... ..............Private CT <br /> Sand El Silt 0 Clay 0 Peat 0 Sandy Loam IZ( Clay Loom E3, <br /> Hardpan[] Adobe[3 Fill Material ............ if yes,type............... ............ <br /> (Plot plan, showing size of lot,-lo&tlon of system in relaflon, to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION. (No septic tank� or'seepage pit Permitted If public tower is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANKI size................................................ Liquid,Depth ............ ........... <br /> Capacity .............. <br /> ...... T * ------I............. Material...................... No. Compartments ..................... <br /> Distance--to–nearest: Well .............4.�......................Foundation ...........--....... Prop. Una ...................... <br /> No. of ones ..2.......... <br /> LEACHING LINE ---------v!'----4en�th of each line.. ...... Total Length ............................ . <br /> D.' Box --------------Ty--p—& Filte� Material –'.1................Depth Finer Material ......:..........--•--•----- ..........._.in . <br /> t <br /> Distance tonearest. Well ......._.....I. .._....... Foundation ......................... Property Una ......................... <br /> SEEPAGE PIT H Depth ................... Diameter ....... Number ............................ Rock Filled Yes [3 No (3 <br /> Water.Tablo,DiIA ----------------------------- ..................Rack Size .......... ............... <br /> ................... <br /> Distance to nearest: Well --------. ................Foundation .................... Prop. Una <br /> REPAIR ADDITION Prev. Sanitation.Permit#............. ......................... Daft ....................... .......... <br /> Septic Tank (Specify Requirements) ............ <br /> ................................. <br /> •.............. ....... ...................... .................... <br /> Disposal Field ISpecify Requirementil- <br /> ------------- .............. -------*......­..........*...............*........................... ...... <br /> i6----------------------------------------------.................................*.............................*.................. ....... <br /> raw existing and required'addition an reverse gidel <br /> I hereby codify that I have prepared.this application and that the work will be darts In accordarwo with Son Jmqutn <br /> ---------- .......I----------------I– <br /> County Ordinances.' State Lows, and Rules and Regulations of the Son Joaquin Local Health,District. Rome owner or Ilem <br /> sod agents signature codifies the following: <br /> "I certify that in the performance of the work for'whlch this permit is Issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Compensadon laws all California." <br /> Signed .-------•-•...................... Owner <br /> By --- .................. ......... Title ------ <br /> of 04�r-than owner) . ............................ <br /> ----------- <br /> POR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ..... 10- - / <br /> .....................................---........ <br /> BUILDING PERMIT ISSUED _•--.---•---------------.-- ... ......... ........I..................... DATr ,/ –:?4 .-,.J.................. <br /> . ......DATE............................................ <br /> ADDITIONAL COMMENTS ................................ ------------- <br /> -----------------*-------- ................ .............................. .......I........................ ................. ...... .......... -------------- <br /> .......... .......•-....--– --.........11...................I................................. ..................................••................................. ............*........................... <br /> ............... ----- ---------------------- ....e–a...... ......... .............................................................. <br /> Final Inspection by: ............... Date 2" <br /> EH -13 2111-6t3 Rev. 5k ........ <br /> 8/74 3M <br />