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FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT <br /> ....... ............._.­........... Perm'It N <br /> (Complete In Triplicate) <br /> ..........._................. d 7 <br /> This Permit Expires I Year From Onto Issued <br /> Date Issue <br /> .............................................. <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is mode in compliance with County Ordinance No. 549 and existing Rules and Regulationst <br /> L <br /> -JOB ADDRESS/LOC <br /> 10 ._ ...... <br /> ....................................CENSUS CENSUS TRAC17 ........... <br /> Owner's Name Phon4 `..6.....431"3.&--- <br /> Address Ira- ---- -----­------------ .......... ............ city 2 <br /> .. ........................... .. <br /> Contractor's Name ---------------------I-------------- -------- ­­--------­--License ----------------.--. Phone ----......-----------•- ...... <br /> Installation will serve: Residence E! Apartment House C] Commercial[3Traller Court 0 <br /> Motel 0 Other ---------------- --------------------------- 63-41X.. <br /> Number of,living units:_-__-t----- Number of bedrooms ------Garbage Grinder ----- <br /> Lot Size . <br /> Water Supplyt. Public System and name - ---= - ----- -------------------------------------1............L.................... --------------...Private <br /> Character of soil to a depth of 3 feet: an <br /> Silt F] Clay 0 Peat 0 Sandy Loom 0 Clay Loom 0 <br /> Hardpan ❑ Adobe 0 fill M6terlal ............ 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 permittedifp --- Liquid Depth ------------- .......ubliF sew ri, v, '10 e within 200 feet,}PAC GE TREATMENT [ ] SEPTfCTAMC jj Size.. <br /> Capacity -----------------_-- Type Material......----------....__ No. Compartments <br /> Distance to nearest. Well .......yv" ---------Foundation - Prop. Line ---------_----S7 <br /> -1 <br /> LEACHING LINE No. of Lines __3----_----------- Length of each line.-.--/ .............. Total Length .........................._0 <br /> V Box ___.--1..._. Type Filter Material Z�1 _ .t-....Depth filter Material ............. ................. <br /> Distance to nearest: Well _/.14P.... ...... Foundation ----/.!p............. Property Line .......... <br /> SEEPAGE PIT Depth .................... Diameter .._,,g.......__. Number .-------------------_...... Rock Filled Yes [3 No <br /> Water Table Depth ......... -------------Rock Size --------------- ................. <br /> Distance to nearest: Well --------------------- --- -----------Foundation -------------_---- Prop. Line ....-_....-••.--•---- <br /> REPAIR/ADDITION tPrev. Sanitation Permit` __-----•--------------------------------- Date ---------_----_-------•--------) <br /> .... ......... <br /> Septic Tank {Speitify Requirements) ------------_................................. ........ .........­1­..........­..............I...... <br /> Disposal Field (Specify Requirements} ..............._------- --_-------------------_- ---------- -------- ---------- ----------------____--------------1­__ <br /> ------------------------------------------------------I--------------------------------------------------------------------------I-----------------------------------------------­­­-------------­...'- <br /> ---------------------------------- ---------­d--------- ---------------------------------------------------------­------ ---------- ---------------I——­---------­----------------•-- <br /> ] (Draw existing and required addition on reverse side) <br /> E. I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Hama 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 employ any person In such manner <br /> as to beta 1e to Comperi., aws of California." <br /> ............................... Owner <br /> Signed V-0stz; <br /> By ------------------------------------------------------------------------*----------------------------- Title ..--------- ......... ------------------ --------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 7 <br /> APPLICATION ACCEPTED By .k - -- ----------------------- DATE ....6 <br /> --------C�ATE .._.....- <br /> ADDITIONAL <br /> .. ........................ ........ <br /> BUILDING PERMIT ISSUED ---- ------- ------ <br /> --- ----------I............ .....J.. <br /> ADDITIONAL COMMENTS --- --- <br /> --------------------- -------------------- ------ ------------------------------•..__--__----- --•---•••---•--- .............. <br /> ........... ........... .......... -------------- <br /> ---------- ----------------- <br /> - ....... <br /> ----------- ---- ------ ----------- <br /> 2- ­--------------------Dat_/___ �iy <br /> .......... ----------- <br /> final Inspection by: ------- <br /> EH 13 2h 1-68 Rev. 5� SAN JOAQUIN LOCAL HEALTH DISTRICT 3M <br />