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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ..................... <br /> 7 <br /> ----------- ....... --------- (Complete p <br />""--'•"'"" Com late in Triplicate) <br />----..-.....-.11........ <br /> `� Date issued ....�_�:3.•_••. <br /> This Permit Expires T Year From Date Issued <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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> �- D ..........CENSUS TRACT .......................... <br /> JOB ADDRESS/LOCATIO I- -:- r F ....... <br /> p <br /> ....""....-.. / "........._.....................-.,Phone .... .................. <br /> Owner's Name .....•_. <br /> !a mea......-.. <br /> Address - f-'T- --...."" ... city <br /> ' Phone <br /> Contractor's Name ...... + .—...... License # .�� <br /> - KIl <br /> Installation will serve: Residence E] Apartment House❑ Commercial❑Trailer Court 0 <br /> Motel ❑Other .. i <br /> Number of living units:_:..�3_" Number of bedrooms ----Garbage Grinder ............ Lot Size ..._. "- <br /> Water Supply: Public System and name__________________ ....--------.•........---..•......----•-. . •••••-_.....Private i <br /> Character of soil to a depth of 3 feet: Sand❑ Silt[ Clay C] Peat❑ Sandy Loam❑ Clay loam <br /> Hardpan 0 Adobe'❑ Fill-Material ............ 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 /> • i <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 204 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] .`.. Liquid Depth <br /> Size.... ....................:.... <br /> +} Material.... ..-... _ No. Compartments <br /> Ca aci Type 'J <br /> 4 . <br /> Distance.to nearest: Well .........._ ..............Foundation ...----......------_--,Prop. tine _..........-----•---•• <br /> LEACHING LINE [ ] No. of Lines .--_-_---•-----._ Length of each line.._.__'.-____...- <br />` --•---- Len -......._.. Total Length ."..."...................... <br /> 'D' Box __ -------- Type Filter Material "...................Depth .Filter Material ;......................................••--•� <br /> Property Line <br /> Distance to nearest: Well ----•-,------------.... Foundation ........................ p ty ........----------...--- <br /> R ck Filled Yes ❑ No <br /> SEEPAGE PIT } Depth -_-___. Diameter .... -------- Number --------- <br /> Water <br /> -• <br /> Rock Size ... ..._.. . <br /> Table Depth _. ••. <br /> Distance F ........................................ <br /> .. R <br /> to nearest: Well --------------------•• • Foundation Prop. Line . •� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .................•------------------ 4.Date ........... 1 <br /> Septic Tank (Specify Requirements) ------- •--- •......................... .........................................................•_----_-..._••--"� <br /> I ----- s . <br /> Disposal Field <br /> IS i#y Req rrements) --•---------- --• ------ _. ;t-- . .-,.- <br /> --" �- <br /> -------------------•--• -----"""--------.-----------• ------- - <br /> ........._.................... •-.----...----.------ " <br /> {Draw existing and required addition on reverse side) <br /> 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, wind Rules and Regulations of the San Joaquin Local Health:District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I terrify 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 ---- Owner r^- <br /> By ------ ---.--: ------------ ,...-" -•-------- Yitle f- - - - ------------- --- ...----- -----• <br /> (If other than owner) <br /> j FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - - - - -------------- ----------------•--•-•----------- ---------------- DATE <br /> k BUILDINGPERMIT ISSUED -------- ---- ----------- -- DATE <br /> ADDITIONALCOMMENTS ---------- ° ------------•..............................................�-............----.......................-------- ----- <br /> r ----•---- ------ ---" <br /> ----- ----------------- -----------•-•---- <br /> r ----------•---•-•----------------""...t-•--•---•---•---... --•---•---------- -•------ ---- <br /> -------------- ---------•--------•-•-- r -- -------- <br /> --.... ...---............. <br /> . <br /> Final Inspection by: . ..............................Date . .... . ' <br /> ' MH 1.3 Zit 1-68 Itev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> s <br />