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FOR OFFICE USEt' <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br />..............I...............r............. ....... <br /> (Comploje In Triplicate) <br />..........I......_._.................. ............. Date <br /> ........ ..................... .............. <br /> This Permit Ex fres I Year from Do%Isjued <br /> Application is hereby made to t,he 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 /> JOB ADDRfSSAOCAT1ON9!ZZ?A......i; �C-ENSUS TRA <br /> . ...... . ...... <br /> 4 .,FF9/_ , <br /> Owner's Name ...... ..Phone <br /> . ... <br /> Address ............................................... ........City <br /> ................. .. <br /> ............. <br /> Contractor's Name --_------------ ............................................. .......... ...License ........................ Phone -----............ <br /> Installation will'serve. Residence XApartment House 0 Commercial roller Court 0 <br /> 'Motel 0 Other............................................ <br /> Number of living units:...! Number of bedrooms I.--Garbage Grinder .... ....... Lot Size A?' AliqZ-V ......... <br /> Water Supply. Public System and name . ......................---.:....-__---.--.----•--:....-_.-...........................•-----_. ...._.......Private <br /> Character of soil to.a depth of 3 feet.- Sand Silt ClayC3 Peato Sandy Loam 0 Clay LoamA <br /> HardponA Adobe Filldaterial ............ If yes,type............... ............ <br /> JI'lotplan, 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 seepage pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT SEPTIC TANK11 ee,,r,t 'Size...........12,02�........................... Liquid Depth ........... <br /> Capacity --------------•----- Type ----------------__ material...................... .No. Compartments --- .........--------- <br /> OQ <br /> Distance.to nearest: Well ....................Foundation ...................... Prop. Line ........................ <br /> LEACHING LINE j No. of Lines ---/----------------- Length of"each line------ Total Length ..qo................. <br /> v Box LL94__ Type Filter Material .61..�!Z [Depth Filter Material 14?.... ['T1 <br /> C7 <br /> Distance to nearest.. Well ...... ........ Foundation ............. .......... Property Line ........... ............ <br /> I I • <br /> yes N <br /> SftPAGE-NT Depth jo.-fl-W.W. Ok"er ... Number ...._/................... Rock Filled o 0 <br /> v�v <br /> A <br /> Water Table Depth .............. .......... ......................Rock Size .4 =.,7. <br /> Distance to nearest- Well­06e'kF?C__/j9.-.V........Foundation .................... Prop. Line........................ 3 <br /> V <br /> REPAIRADDITION(Prev. Sanitation Permit# ............................................. Date .................................. <br /> . .1 ................................................. <br /> Septic Tank (Specify Requirements)..:................•---- ....... <br /> Disposal Field (Specify Requirements) ................... <br /> ............... 4.......... .................................•................................... <br /> ---------- ..... ................ <br /> ........................ .................................... <br /> -_------------------- ------........... ...or_...................-----------------------------------------------(Draw existing and required addition reverse side)aI hereby certify that I have preparid this application and that thewk will be don* In accordance with Son Joaquin <br /> County Ordinances, State Laws, -and kules7and Regulations of the San Joaquin Local Health,,District. Home owner or licen- <br /> sed agents signature certifies the folio-wing:I I shall not employ any person In such manner <br /> "I certify that Irvthe perfarmanci-ofjhe work for'which this permit Is Issued, <br /> as to become ubject to Work on, of California." <br /> Signed --- ------------------ Owner <br /> By ...... ---------------------------------- ---­--­------- Jitle ... ----------------------------------- ..................... <br /> (If other than owner) <br /> •0 Di:' MINT USIE ONLY. <br /> 7 <br /> DATE.... .... 9,� <br /> .................. ------ - -------------------- <br /> APPLICATION ACCEPTED BY -- --- -- ----- ... ... . -- -----------I.,------------------­ <br /> ........-.-...-.-.. <br /> ........ ................ <br /> BUILDING PERMIT ISSUED'------- ............__.................----•--a........ <br /> .....­--------------------------------------- ----...DATE ----- ......... <br /> ADDITIONALCOMMENTS ---••--•-•...-----•- -11--------------- ...........:..................................................................... ..................................•-- <br /> :-----------•---------- <br /> ..................... <br /> -----------*-------*----------*------------------------------------------------ ....... <br /> -------------------------------- -----------------------------------------*------------------- <br /> ....................-.1------------------- ------I-------:---------------------------------- ­I------ -----­ -----....-...._....•-___-1------­...................... ....... <br /> --- ................ <br /> . ......... .................... •--------...., <br /> ----------- <br /> -­-----------­--A <br /> ---- ---- ---- ... ........ <br /> Date <br /> Final Inspection by. ....... ....... . <br /> EH 13 24 1-68 Rev. 5M SAN JOAQUIN I PCAL .HEAtTH DISTRICT 8/74 3M <br />