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FOR OFFICE U.S E! APPLICATION FOR SANITATION PERMIT <br /> ................... . . .......... Permit <br /> . (Complete in Triplicate) <br /> ............ . <br /> ............... This Permit Expires I Year From Date Issued Date Issved _ <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 compliarce with County Ordinance No. 549 and existing Rules and Regulations- <br /> CENSUS TRACT ..................... <br /> JOB ADDRESS/LOCATION ..... <br /> Owner's Name _1... ..... ............... ....... ... Phone ...... ....... <br /> . <br /> Address .. ...... City .................. . <br /> Contractor's Name .......License #1*9 Phone .............................. <br /> Installation will serve: Residence Apartment Hausa❑ Commercial ❑Trailer Court C] <br /> Motel El Other................... .....P........­ ­­ <br /> Number of living units..._/._... Number of bedroom s_3.. Garbage Grinder ......... Lot Size ...................................... <br /> Water Supply: Public System and name .............. ....._........................Private <br /> Character of soil to a depth of 3 feet: Sand'C1 Silt 0 Cloy El Peat El Sandy Loam El Clay Loam <br /> ❑ <br /> Hardpan Adobe [] Fill Material __ __ If Yes,type ... . ........ <br /> (Plat plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION- INo septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT SEPTIC TANK I j Size..... Liquid Depth .......................... k� <br /> . _r <br /> Capacity ..................... Type -------------_-__ Moterlal___ No. Compartments .......... <br /> Distance to nearest. Well .._........Foundation Prop. Line..................... <br /> LEACHING LINE No. of Lines .. ....... Length of each line............................ Total Length <br /> 'D* Box ....___ Type Filter Material ...... Depth Filter Material .............................. <br /> Distance to nearest: Well . __.................. Foundation ............... Property Line ....................... <br /> SEEPAGE PIT Depth ...... Diam#ter ............. Number .:-....... ................. Rock Filled Yes r7 No CJ <br /> Water Table Depth ............Rock Size ................. <br /> Distance to nearest: Well ... ...................:.__...._::...foundation.............. Prop. Line ................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit#' ........------- --- ------- ......... Date ...........--------------------- <br /> Septic Tank (Specify Requirements) ....................... ............ ........................................................ <br /> Disposal Field (Specify Requirements) .... ...... ........ <br /> n 4''�._....f... . �........:.. ..?:.'.'xr� G !- ............ <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 he done In act6rdente with Son Joaquin <br /> County Ordinances, State Lows, and Rules and Regulations of the Son Joaquin Local Health District. Ham* owner or (icon- <br /> sod agents signature certifies the following: <br /> "I certify that in the pedarmance of the work for which this permit is issued, I shall not employ any person In such manner <br /> as to become subject to W* k Compensation laws of California.- <br /> Signed .... <br /> -1-j �. ... . Owner— <br /> Byty Title .............. <br /> (if other than a <br /> AOR DEPARTMENT USE ONLY <br /> APPLICATION ACCE_­ DATE.77 74............... <br /> PTED B Y ................. .......I............... <br /> BUILDINGPERMIT ISSUED .................................................... ................... .............. .............. <br /> ADDITIONALCOMMENTS .......................------_......_............. ...... ................... <br /> ...........­­­I....­........ ..............................­..................................................... ....... ........... ....... ..................... <br /> ........... ...... _.............- ...­ ' <br /> ......................-.-.--------------------..-.-.-..--.-..--.-. --- .V..Z...­­�­......... ...... <br /> Final Inspection by: ....... ............ 77 . ....................... <br /> ... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> *--E, H. 9 1-'68 Rev. 5M <br />