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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .....................•----...A..._ 4.............. <br /> .......... <br /> Permit No. ..Za <br /> .... . <br /> ....... •..........-•......•---•.............. <br /> [Complete In TAplitafe) <br />..................... ................N.............. This Permit Expires I Year From Date Issued Doti Issued ..-`0.......��S­ <br /> Application is hereby made to the Son Jooq6in--Loca'I Health District for a permit to construi:t and Install the work herein <br /> described. This application is made in complioncewith County Ordinance No. 549 and existing Rules and Regvlotionst <br /> JOB ADDRESS/1.0 <br /> ............ . <br /> rr <br /> ............... <br /> CAT1,qsI ............ ...................CENSUS TP.Aa ....... <br /> Owner's Name -­­'-Lt�-----7—z.... . ..... .............................. ..............:.....................P hone .................................. <br /> 11D <br /> Address ........................4 .::City <br /> .............. ------------ <br /> icense <br /> Contractor's Name <br /> # ......... ........... Phone ........ ...................--= <br /> Installation will Zervllt: Residence rtment House O'Commerclal OTraller Couit 0 <br /> Motel her <br /> ............ ,- •;•. ............ <br /> ,of living units: (3 Ot <br /> Number Num- of bedrooms ....._Garbo ge C:On�der, <br /> ,4....4)...Acit Size <br /> Water Supply: Public System and home ............. .......................... ...... ................. <br /> ...-.:_...:................-......._.....Private <br /> Character of soil to a depth of 3 feet. Sand 0 Silt 0 Clay 0 Peat 0 Sandy Loam 0 Clay Loom <br /> Fill M6terlol ......If yes",type............... ............ <br /> (Plot plan, showing size of lot, loixition of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATIONt. (No septic tank or seepage pit permitted if public sewer is-available within-200 feet;) <br /> PACKAGE TREATMENT SEPTIC TANK Size........­­­­­,. ..................... Liquid Depth ............... <br /> Capacity ---•---------------- Type ----­­-­---- Material.. N6., Compartments <br /> ....... .... 0 ...................... <br /> Distance to' nearest-..Well .....................................Foundation ............. Prop. Line. . ........ <br /> I <br /> LEACHING LINE No. of Lines --- .................... Length of each line.... .................. Tafai <br /> Length .........................-.-(J <br /> 'D' Box .............. Type Filter Material .........Depth filter Material ...L.-.1.................................. <br /> Distance to nearest: Well .......................-Founclation ...............n'-7-!7: Property Line......................... <br /> SEEPAGE PIT, Depth ------- Diameter-- ............ Number -------------- . Rock Filled Yes 0 No 0 <br /> Water TableDep. . ..........I............I. •.................Rock Size ...............v................ <br /> O <br /> Distance to nearest: Well ............................... .......Foundation ..................... Prop. Line .... ................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___......_.._..•-------------------•---_:-... Date ------- -- <br /> Septic Tank (Specify Requirements) ........... ....... .................zq­­ .......... . <br /> Disposal-„Field--(�peclfy Reclyirements) <br /> .......................... <br /> ------------- ...... <br /> F <br /> ------------ <br /> - -` - --------- <br /> ---------- <br /> ............ ......... ..................... ............ ............................. ................. .............................-------------------------- <br /> ..................... ------------------------ ................................. ............. ............................................................. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this applicallwahal-that thf'work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and: Rules and Regulations of the Son Joaquin Local ReaII&DIstrild. Morn* owner or 11cew <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 ---- -------- 1- ------------- <br /> .......... -----­-----­' Owner <br /> ::,*-------------- <br /> By .... ------------ - ---- ---------- Title <br /> ............. --------------­- . ...... <br /> ather an owner) <br /> FOPY,DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ......�­ - ------ <br /> ----=- ----••-------- ........... <br /> BUILDING PEWIT ISSUED --------- ....... - <br /> /...................•--•--- DATE <br /> --------------------------DATE ................................ ....... <br /> ADDITIONAL COMMENTS <br /> ....................I.......... <br /> ---------------­--------- ............ -------- -----------------­ ------------ .................. -----­----­-----------­---I--------- ---­­------------------- <br /> .......... ---------------­­­_---------- --------------------------------------------------- ............. ...................... .................... ........ <br /> -4 <br /> ------------­-*-------­­-­­­­............ ...... ...... <br /> .. ................. ­.......... ------------- ..................... <br /> final Inspection by: ........................ ..................................... . <br /> -­----Date V ........ <br /> EH 13 24 1-6 8 Rev. 5m <br /> SAN JOAQUIN LOCAL HEALTH TRIeCT <br /> 8/711 3N <br />