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FOR OFFICE USE: <br />........ APPLICATION FOR SANITATION PERMIT <br />....... ..................... (Complete in Triplicate) Permit No. <br />... . .... This Permit Expires Date Issued -,71 <br />........... I Year From Date Issued <br />Application is hereby made to the SonJoaquin '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 ADDRESS/LOCATION ,..3;a,12.Eaa.t. W0.*-ds.sn_R*ad.,. Acampe . .......... ........ CENSUS TRACT `SY.6,....____._.... <br />Owner's Name ..................... ....... .. ......... ............ .................... .. _Phone _3.68,!-!,172Q i I <br />Address ... <br />....... ...... City _ACALInpa. ._ ...... ­ .............................. <br />Contractor's Nome ... .....License # Phone 10M.483-84171 <br />Installation will serves Residence [] Apartment House E] Commercial X]Trailer Court 0 <br />Motel [.1 Other .... ..... ....... <br />Number of living units...P.. Number of bedrooms ......,_.Garbage Grinder _ Lot Size <br />Water Supply: Public System and name ....WAtar __W'11 "e ...... <br />'. _ ----- -------- * ...... * -- - ----------- ----------- ...... ...... Private <br />Character of soil to a depth of 3 feet: Sand Ej Silt C] C I a y [7] Peat 0 Sandy Loom C] Clay Loom M1 <br />Hardpan _IC. AdobeFiJlMoiterial ... .... If yes, <br />(Plot plan, showing size of lot, loc <br />at'an Of system in relation to wells, buildings, etcmust be placed on reverse slde.i <br />NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200 feet,)W <br />PACKAGE TREATMENT SEPTIC TANK Size ...... Liquid Depth ......................... <br />Capacityl000 .... Type Material... ��00C.X*0..teNo. Compartments -2 .............. . . <br />Distance to nearest: well 5 <br />,.Q! ........ ._,...Foundation ------ Prop. Line .......... . <br />LEACHING LINE J No. of Lines Length of 'each line_.4.0t ..... Total Length . ...... A(l............... <br />'D* Box _.... , Type Filter Material XY00hc'd Depth Filter Material <br />Distance to nearest: Well . 100 f gVA*ar&­ <br />5EEPAGE PIT . . .... .... ... Foundation ..... ............. ... Property Line ........ <br />Depth Diameter __ Number , - Z ... ....... ... Rock Filled Yes No (C3] <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 />. . . . . . . . . . . <br />. . . . . . . . . . <br />side( <br />(Draw existing and required addition on reverse s I <br />I hereby certify that I hove prepared this application and that the work will he don* in accordance with Son Joaquin <br />County Ordinances, State laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br />sed agents signature certifies the following - <br />"I certify that in the performance of the work for which this permit is issued, I shall not emy" per <br />loperson in such manner <br />as to become sublOct to Workman's Compensation laws of California.""` <br />Signe <br />Owner <br />By:P`�e S )dent <br />Title <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED SY_ <br />BUILDING PERMIT ISSUED ...... __­ ----------- ... ........ ___ DATE <br />............. . ........ ---------- <br />ADDITIONAL COMMENTS ....... .DATE ... _._ ........... -- -------- <br />.......... ............ <br />.................. ...... <br />................... __ , <br />8 ion .......... ........ <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1-'b9 Rev. 5M <br />