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FOR OFFICE USE: <br /> ........I......... ...... ...... ...... APPLICATION FOR SANITATION PERMIT -. <br /> 11COMPItto In Triplicate) Permit No. 2 5�3 <br /> ........... ........................... ............ <br /> .......... —7( <br /> .......... ------------ This Permit Expires I Year From Date Issued Date Issued .49 ......... . <br /> I <br /> I Application is hereby made to the Son'Joaquin Local Health District for <br /> f described. This application is made in compliance with County Ordinancea W' construct and install the work herein <br /> i NO. 5a9andexisting Rules and Regulations.. <br /> JOB ADDRESSAOCATIO <br /> .............................I............ <br /> Owner's Name .......... .....CENSUS TRACT .......................... <br /> .......... .................... ...... <br /> Address ...... Ph no <br /> .............. <br /> city <br /> . ..... .... .. -- ----- <br /> ........ .. <br /> Contractor's Name ------------- ---------- ...... .......... . <br /> . ....... ....... <br /> ------- --------- ..... ..License 'I. .....�Pfion4 <br /> Installation will serve: Residence Apartment Hou$00 Commercial OTrallet.Court 0 <br /> Motel 0 Other <br /> Number of living units:_._..-_ u <br /> -t. N I mber a e ms _.. ......Gorhqge Grinder ............ Lot Size <br /> Water Supply: Public System and name .............. ........."............ <br /> ...... .........................I................. ......... ..........Private <br /> Character soil too depth of 3 feet. SandO Silto CIO X <br /> YO Peato "yLOom.t3 Clayloam E) <br /> es,ty . ...... <br /> 7-'-HUr-dpdn-_0—Ad-obe X Fill Material ............ If Y. <br /> ........... <br /> (Plot plan, showing size of lot, location Of system In rotation to wells, buildings, etc, must be Placed on reverse side.) <br /> NEW INSTALLATIq14 ' (No septic tank or seepage pit.permitted if public sewer Is available within 200 feet, <br /> PACKAGE TREATMENT SEPTIC TANK[ size....... <br /> ---------------------------------- Liquid Depth ........................... <br /> •_.Copacity, --------------- Ty <br /> ................ Material--•-•-.... <br /> ........... �No'._Compartments ...................... <br /> Distance. to nearest: Well <br /> ............. ...... F ndation ......... Prop. Line ................. <br /> LEACHING LINE No. OU <br /> e.,7, 'Total Length ..... <br /> of Lines ------------------------ Length of ea -___F <br /> ------*---- ---- <br /> V Box .............. <br /> I—.... Type Filter Material I.-V...............Depth Filter Material ............... <br /> Distance to 4 nearest: Well ...... .................... <br /> SEEPAGE PIT Depth .........!............ Diameter .-,.......... FoVndotion ......................... Property Line ........................ <br /> .... Number ..............__.. <br /> ------ Rock Filled Yes [I No 0] <br /> Water Table Depth ..... ................. <br /> . I ..........---_Rock Size ....................... <br /> Distance to nearest: Well .............. ......... P <br /> ....................4.Foundotton Prop. Line ....4............ <br /> REPAIRADDITION(Prev. Sanitation Permit# • <br /> -------------------------­----------------- Date ........ <br /> Septic Tank (tioecify-796quirements'll---------------- ----------_---_ <br /> .............. .............. ..... <br /> Disposal Field-N'&cify Requirementsl ............ .................. <br /> -,� _I <br /> ....... <br /> . .......... .. <br /> U ........ ................... <br /> ----------------- - <br /> ------------ <br /> --------------- - ............... <br /> ------------------------- <br /> ----------I----------- -------------­--- ---------- ----------­ <br /> ............... ................................. <br /> (Draw existing and required addition on.reverse side) ------- <br /> I hereby certify that I have ,prepared this application and that the work wtEbe done' in accordance with Son. Joaquin <br /> County Ordinances, State Lows,�and.Rules and Regulations of the- an Joaqvin-to <br /> sed agents.signature certifies the following: Cal Hoalth�District. Home owner or titan- <br /> sed <br /> certify that in the performance of the work for which'thii-Wennif is issued_'l *hall not Lem lay any person In such manner <br /> to become subject to Workman's Compensation laws of California." <br /> Signed -;...... <br /> Owner <br /> By .... ....O�----- <br /> -C ................... <br /> (if 0 e than owner) -------------- -------- ........ ....... <br /> wry <br /> FOR DEPARTMENT USE ONLY <br /> A' Y <br /> FOR DEPARTMENT 1 M <br /> APPLICATION ACCEPTED BY <br /> ... ......... <br /> -- --- <br /> BUILDING PERMIT ISSUED j----------------------- -- - ------ <br /> ADDITIONAL COMMENTS .... I ----------*---- --------.--------••---------------------------------------DATE ............................. <br /> ............. . ------ ........�:----------­---­ ------ <br /> ---------- ------------L ................ ....... .... .. . ...................I...................­........ <br /> --.............. <br /> ----....................­............... <br /> -------------I------- <br /> -------- ----------------*----------------- ---- --------------- <br /> ------- :--------------------- ------------------ --- ------- <br /> ----------------------------------: 7-, .. --- -I----------- ..................................... --------------------- <br /> ------------------ ------- ........... ------------- <br /> Final Inspection by: --------- <br /> ?."Ie............ <br /> EH 13 2 e . ... Date _f_n...... <br /> 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />