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FOR OFFICE USE; <br />APPLICATION FOR SANITATION PERMIT <br />......................................................... <br />(Complete In Triplicate) <br />Permit No. <br />........................... ...... I ...................... <br />Date Issued <br />...................................._.......I.......This Permit Expires I Year From Date Issued <br />Application is hereby mode to the Son Joaquin Local Health District for a permit to construct and install the work heroin <br />described. This application is mode in compliance with County Ordinance No. 549 and existing Rules and Regulcfflons: <br />L&P <br />JOB ADDRESS/LOCAT ....... fG........ I_ .................. .............................. MSIJS TRACT ....... ................. <br />Owner*r, Name ........ ..... ................... .. ............ .....Phone ............. - ......... <br />... Cit, ....... <br />.......... ........ ..Address ...... ............ ------ <br />Contractor's Name <br />. ..... .........License # Phone .......... ................ <br />Installation will serve: Residence 0 Apartment House 0 Commardal OTraller Court 0 <br />Motel 0 Other.... <br />--------------- <br />Number of living Units.-. ........... Number of bedrooms ......._...Garbage Grinder ............ Lot Size ....... ------------------------------------ <br />Water Supply: Public System and name........... ❑------------ ------ . .... . ..... . ............................ Private U <br />Character of soil to a depth of 3 feet: Sand Silt 0 Clay 0 Peat 0 Sandy Loom 0 Clay Loom 0 <br />Hardpan ❑ Adobe 0 Fill M6teflal ............ if yes, type ........................... <br />(Plot plan, 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 available within 200 feet,) <br />PACKAGE TREATMENT SEPTIC TANK I Size ................... : ............. ............... Liquid Depth .................... <br />Capacity .................... Type --------- .......... Material ...................... No. Compartments ............. I ...... <br />Distance to nearest: Well ...... ..............................Foundation ...................... Prop. Line ......... <br />LEACHING LINE No. of Lines ------------------------ Length of each line......_..................... Total Length ................. ; .......... <br />V Box ......... _ Type Filter Material ....................Depth filter Material ... .......... .......................... <br />rM <br />Distance to nearest: Well ........................ Foundation ----- -_-_------_-- Property Line ........................ <br />SEEPAGE PIT Depth _---_------------ Diameter ................ Number -----_--------__------ Rock Filled Yes 0 No 0 <br />Water Table Depth ................................................ Rock Size .............. ------_------- CC <br />- <br />Distance to nearest: Well ........................................Foundation .................... Prop. Line .._..._•....•.........4 <br />0� <br />REPAIR/ADDITION (Prey. Sanitation Permit# ............................................ Date ................_•..----•_-- ----- 11 <br />Septic Tank (Specify Requirements) ------------------------------------------- : ................................ - -------- . ......... <br />Disposal Field (Specify Requirements) -y - ----- -------------------- <br />.......... 2 '41.e <br />.. ............. ------------------------------------------------------------------- <br />. <br />....................................... ................ --------- ------------- ------- ...... ------- ---- - -------- ­­ ----------------- I ............................. ...................... <br />(Draw existing and required addition on reverse sidel <br />I hereby certify that I have prepared this application and that the work -will he done In accordance with Son Joaquin <br />County Ordinances, State Laws, and Rules and Regulations of the San Joaquin"LWcal flealth,01isfrict. Home owner 4W DOW <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 employ any person In such manner <br />as to become subject to Workman's Compensation laws of California." <br />Signed-------------------- ---------------------------- a_._ ------- Owner 1 -- <br />By ------------ ....... ................ 40 Title .......... <br />....... .... .... .................. .............. <br />(if other than owner) '7 <br />FOR g!PARTMENT USE ONLY <br />APPLICATION ACCEPTED BY ...... .............................. ---------_ __ -------- DATE A - — - ----------------- <br />... * ------------------- <br />BUILDING PERMIT ISSUED ............ -----_--_--- ------ ------ ­­ --------------- .............. DATE . ........... <br />ADDITIONALCOMMENTS ... .................................. / _------------------ —.1.1--.1 ...... ............ ................... ....................... ____ ...... <br />.... ... ........................ ­­ ............ ....... .. -.1 -------------------------- ......... .. ­------------------------ - - <br />----------- ­­ .......... ......... I ........... .... ...... ....................... .... I ---- ­­ ....... ............... ................. ­ -------- <br />----------- ----------- ....... ....... ... ...... ............................ ......... ........ ---------------------------------------- ---- <br />finalInspection by::.... .................................. .......... a.._ ..................................... Date <br />EH 13 24 1-681 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />