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r FOR OFFICE USE- ✓ APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------.•..:......... ...... (Complete in Triplicate) <br /> Date issued <br /> ......................... <br /> This Permit Exp fires 3 Year from Dal Issued <br /> e woA <br /> Application is hereby made to the Son corn lion eLocal Health District <br /> i tri t for Ordinance permit <br /> and exis <br /> ting ink Rulesand talndhRegulationseln. <br /> � described. This application is ,a p <br /> 16q opo i''lI . k l ie cl: CT ................ <br /> NSUS TRA --•- <br /> JOB ADDRESS/LOC ION ... .... <br /> ���?�_ -�-- Phone .................................... <br /> Owner's Name ..........-• ............................... <br /> ...................... <br /> City ......................................... ............................. <br /> Address ................_.-•-----....._..-....---...._...._-..-...----.....-----••--•-...._.._......:.----..... 1 2 _ <br /> Contractor's Name ....� ----� •----- <br /> License Z9 4 Phone . Y <br /> Installation will serve: Residence❑Apartment House�] CommercialTraller Court C3 <br /> Motel ❑Other -•-- ..._.... ..... - .. <br /> Lot Size <br /> Garbage Grinder .................. ........ <br /> Number of bedrooms - 9 _........... •- <br /> Number of living units:---••------- ....._....._ <br /> I Private <br /> Water Supply: Public System and name ................_..._ ......... .._ <br /> 4 -----• Peat Sand Loam ❑ Clay Loam <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ ❑ Y <br /> Hardpan❑ Adobe 0 Fill Material ............ If yes,type ............... •... ....... <br /> (Piot plan, showing size of lot, to of system in relation 'to wells, buildings, etc. must be placed on reverse-side.) <br /> ailable within 2QQ feet,) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is av <br /> f <br /> -- � • Liquid Depth <br /> ' SEPTICTANK� ] �......------•-�=.. •-••------2--.......__. { <br /> PACKAGE TREATMENT [ ] Size......---•-•._..._ <br /> r )200 Type - ._ ' � Material_.5 " f!� . No: Compartments •---•---•--.....•----- <br /> Capacity ` <br /> Prop in .... . <br /> - ' � ` ._Foundation D ...- - ---.-. .._ <br /> Line <br /> Distance to nearest: Well ---.. .4?�..................... <br /> Length of each line_:...-. _.. Total Length .......... <br /> LEACHING LINE No. of Lines g <br /> � ) Type <br /> y <br /> Depth .Filter Material . <br /> Box ... ------- T e Filter Material ....._..•--••---•• , <br /> ' tt Foundation A ....... Property Line ... ......••--- ...... <br /> e <br /> _ pistante to nearest: well ._.1_�°__......... - <br /> SEEPAGE PIT O Depth, -------------------- <br /> - -"-------------- Diameter ..........._ Number .....I...I.................. Rock Filled Yes ❑ No 0 <br /> Water Table Depth ._Rock Size <br /> .Foundation .. Prop. Line ....••............. <br /> pistante to nearest- Well --..._.•......... --•-••------••-•-• <br /> tEPA1R ADDlT10N{Prev. Sanitation Permit# ----- -----------•----•-•-----••--......_.__ Date .......•---t- <br /> ............ .......... <br /> Septic Tank (Specify Requirements). ............ <br /> ...... :..:. ..._ <br /> I <br /> Disposal Field (Specify Requirements) ......... .........:.............. ..•••..... ................. <br /> 1 ..................... <br /> �,_.. •. <br /> F ---- ------ ----------------•------......---------•-----------------...-..------•----...---......__•--....._.....••------•.-- <br /> -------- ------ -:. <br /> _(Draw existing and required addition on reverse side) <br /> } ._n �. <br /> !Thereby certify that 1 have prepared this application and that the work will be done In accordance'wtih Satz Joaquin <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Healtk.lalstrict. Heete owner er lieen- <br /> sed agents signature certifies the following: <br /> ' "1 certify that in the performance of the work for which this permit <br /> is Issued, 1 shall nal employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signe --------------------------------------- Owner <br /> "16 Yitle ---•-------- ....... ...... ------- ------.---------•--------••- <br /> ( ther than owner) <br /> i DEP RTM T USE ONLY <br /> APPLICATION ACCEPTED BY ---------- --------.- ------------- DATE ....------- -1-' --?�---l-- <br /> BUILDING PERMIT ISSUED .--------- ---------•---------- <br /> --------- -------- - ----------....---------•---------------•--..©ATE .----------------------------------------- <br /> BUILDING <br /> .-_....- ---.._.-....-.--......_...._-. <br /> ADDITIONAL COMMENTS -----------------------------------------------------------•----•-.-. <br /> .............••--.._.-.......-..-.... <br /> 11 <br /> -------------------------------------------------- --------- -------------------------------- <br /> ----- p� ...--......-------- <br /> { ---------------------- -•------ -- ---- --... ........----_.-...---........----.-...--- ----- . ..__-_Date -----// J0---....-. <br /> _ _ <br /> Final Inspection b <br /> p Y ....-....- <br /> ' EH 13 24 1.68 Rev. 5M eAN <br /> OAQUIN LOCAL HEALTH DIST 8/7h. 3M <br />