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FPJZ OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. <br /> ............. ................. ........'•.ji... (Complete In Triplicate) <br /> ..................... <br /> ------**.... .. Date Issued <br /> -- <br /> - ­----­------------------- This Permit Expires I Year From Date Issued <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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> C, 2X^d-V CENSUS TRACT ..........:............... <br /> ................. <br /> JOB ADDkESS/LOC .......... ................Phone ................................. <br /> . 7........... <br /> Owner's Name ........... X.10 ...................... <br /> Address -------------- ................................city ..................... ............................ <br /> 12 Z_ <br /> ..O..JR e"e6's <br /> Contractor's Name ..................... ...................License Phone ............. ........ <br /> Installation will serve: Residence CRApartment House(-I Commercial E]Trailer Court f] <br /> Motel F1 Other -------- _---------i--------_------- <br /> ...... Nt)Mber of bedrooms __-Z..... t Size <br /> Number of living units:---- Gaibage Grinder to <br /> Water Supply: Public Systemand name - ----------------------- -!t�...........I---_----_-----.......••--•--'----- -- <br /> -------Private---------- ...... <br /> Character of soil to a depth of 3 feet. Sand E] Silt❑ Clay-E] Peat El Sandy Loam-[-] Clay Loom.Q5--- <br /> if IS,tyT .... <br /> Hardpan E] Adobe-E] Fill Materidl�...... . . ................. <br /> (Plot pion, 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 public sewer is ovailable Within 200 feet,) <br /> IV <br /> �iquicl Depth .......................... . <br /> PACKAGE TREATMENT li2 SEPTIC TANK 11 Size..................................•.•._:.---•--- I 1�� <br /> Capacity ............ Type.................... Material....-. `........ No. Compartments ---------------------- <br /> _'dation .............. Prop. Line .................. <br /> Distance to nearest: Well ....................................Four. <br /> ;1 t <br /> LEACHING LINE No. of Lines .................... Length of each line . ...._._...F............ ...... Total Length .......•..._.`.._...........Box ...... Type Filter Material ....................Depth Filter Material ................. ......................... <br /> Distance to nearest: Well ........................ Foundation ............. Property Line* ---------------_------- <br /> Yes C] No <br /> SEEPAGE PIT Depth ............ Diameter ................ Number ............. . ...._"\... Rock Filled <br /> WaterTable Depth ................................................Rock Size ............ ................... <br /> Distance to nearest: Well .......... .............................Foundation ----- -------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permii# ..........................................__ Date ._.f..................._......._..1 <br /> Septic Tank (Specify 6tluirements) ..... .......... ............ ...........Af---------------------------------................ <br /> ........................ <br /> -----------------------­­, <br /> Disoosal Field (Specify Requirements) ......./:%--& <br /> ................. 4,e of 1,z------- <br /> ----­----------; ......11 4� .... .. ................ ......... ...............;�........... <br /> ................ .................. <br /> ............................. <br /> ........................................................._:.............................. .. ............ . ............ ............... ....... <br /> d addiii8n onreverse side) <br /> (Draw existing and-require <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 Son Joaquin,Local Health Dis*trict. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of tho.work for which this permit is issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Cornpensatf�n laws-of.California." <br /> Signed ....... --------------------------------- ....... <br /> .................... <br /> By .............. .......... . Title-. <br /> .............................. ...... <br /> (If other than er <br /> 0MENT1 USE ONLY <br /> APPLICATION ACCEPTED BY .... .. . .......... .......................... ............. DATE . ---------------- <br /> BUILDINGPERMIT ISSUED ........... ..........I..............DATE ...................... .................... <br /> ADDITIONAL COMMENTS - ............................... . ........... <br /> ............. ........................... <br /> ........................ - <br /> ..................... ------ .......... .................................. .. ............................... ............................ . ......................... <br /> .................................. p. ............................. ...................................................... --------------1._,h-.......... ---------- <br /> ....... <br /> .................. I I .. ........................... .. .. ............. ................... ............................!.... . ...................... <br /> Final Inspection by.. r <br /> ...... jj.. ......................Date 40. .�........................ . <br /> ...................................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> vi <br /> E.H. 9 1268 Rev. 5M' <br />