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FOR OFFICE USE: <br /> ell / APPLICATION FOR-SANITATION PERMIT <br /> .............................................. <br /> 3 3 v—1 11 (Complete in Triplicate) Permit No. ......... ........... <br /> ..........­............................. 73 <br /> This Permit Expires I Year From Date Issued Date sis U td <br /> ................................ <br /> Application is hereby d to the Son Joaquin Local Health District for--a\_Pler�'"ct 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 /> :...........:...............CENSUS TRACT ................... <br /> JOB ADDRESS/LOCATI <br /> Owner's Name ...... .... ....... ........................................................ ....Phone .............. ..................... <br /> ............................ ........... <br /> ............--•-----• <br /> ... .......................... City ........ <br /> Address ...... .............. <br /> ................................... ...License # Phone <br /> Contractor's Name ..... <br /> Installation will serve. Res;iclehcejxApartment HouseQ Commercial :[DTrailer Court fl <br /> Mo fel 0 C)ther ........ ............................. <br /> f <br /> Number of living units:--A..--.,Number of bedrooms ...X....,..Garboge Grinder .......... <br /> 40. Lot Size <br /> .... 4a <br /> dp <br /> Water Supply. Public Syster and ncirne.`�../.' ........... .................. ........­........... ............ .............................PrivateA <br /> Character of soil to a depthof 3-feet- Sand r Silt[-] Clay 0 " Peat'[:] Sandy Loom C] Clay Loo"now <br /> 7 <br /> Hardpan a <br /> Adobe ❑ Fill M' terial ... ........ If yes, type .,.,---------------- ....... <br /> (Plot plan, showing size of lot; location of. system in :relation toL wells, buildings, etc. must, be�placed on reverse side.) <br /> NEW INSTALLATION: (NE septic tank or seepage pit permitted if public sewer is available within 200 feet.) <br /> PACKAGE TREATMENT SEPTIC TANK t Slze.05 .... Liquid. Depth -.4---—-_---------- <br /> CapacitYe��_... TypMaterial. &. ..... <br /> zeo . No. Compartments ................ U1 <br /> AP, <br /> Distance to nearest: Well ./,le------- ----------_.Foundation ............ Prop. Line <br /> __T <br /> —"i�lWne__ �Ia............... <br /> LEACHING LINE Nq. of -s -K-6-V ea ............... Total Length <br /> Lint - -----------I.... Lenit <br /> -D, Box - Filter ...Depth Filter Material ............ <br /> �4,1. ie er Materia ................... <br /> '!�i ;Y_-4,1.!Type ". 01 / .e , e...... <br /> - 01 <br /> Well'=:-- ---.•---.. JIM.R.i <br /> Distance to nearest:- Foundation . .. ............ Property Line <br /> Yes Na <br /> .. ................... Rock FilledSEEPAGE PIT Depth ...... Diameter .. Num9V <br /> t ..................... _Rock Size ...... <br /> Wd er Table Depth ....... <br /> Distance to.nearest: Well .............. .....Foundation .... Prop. Line 0.......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit.# ....... -----------_ -------- Date ...............------ <br /> .......... <br /> Ali -ts) ............._:'­......................I..........................................---,F•_---••---•--•---...- ........ ............. <br /> Septic lank {specify Regviremen <br /> • <br /> DisposalField (Specify Requirements) ........................•----•---------------------- ......................................................... ............... <br /> ......................... <br /> ........................... ------------------------------------. , . . ....... --------------I-------- ....... <br /> 0---------------------- -------------------- --------------------------------------- ------------------- ............................................. --------- .............-----............... <br /> , a (Draw existing and required addition on-reverse-side)- Lc . . 011J N � <br /> I hereby certify that I havprepared this application and that'.-the work will be done in accordance with qSanJoaquinLTa <br /> County Ordinances, State' ws,-and Rules and Regulations of.,the Son Joaquin Local Health District. Home owner or licen. <br /> 11L <br /> sed agents signature certifies the following: <br /> "I certify that in the perF*Ancnce of the work for whichr this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Wolrkman's Compensation laws of California." <br /> Signed ------ .......... <br /> f. ................................ Owner <br /> .............. <br /> By ......... ........ .... ... .. .... . . . ....... .......... ............• <br /> Title 9 <br /> (if r than'owner) <br /> FOR DEPARTT USE ONLY <br /> gLN <br /> APPLICATION ACCEPTED 8Y . ...... .. ................ ........ DATE ..�...... <br /> BUILDING PERMIT ISSUEDY <br /> ---------- <br /> ...... .. ........ <br /> :............ <br /> CO ......................................... ................... .........DATE............................................ <br /> ADDITIONALCOMMENTS!t........................................................­....... ............................ ------ ....................................................... <br /> ................ <br /> .......................... .......................•.•---------._..............------.._.............I..........I........................I.......................... <br /> . .....7--------------------------------------- ................ ......... <br /> .......................................................... ...... ........................­­..................................... <br /> 'I 1. ...............................11.................. .......­........... ... ----- <br /> ------ .... . .... ....... . .. . <br /> ............. i! <br /> Final inspection by: .. ........:..........::.....:................._..--•-•-.........Date --- <br /> 1 f <br /> In, —SAN.,JOAQUIN_LOCAL HEALTH DISTRICT <br /> r w 13 24 i.-An eav SAA 7/72324 <br />