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FOR OFFICE.1 USE: APPLICATION FOR SANITATION PERMIT Permit No. .--/Z---.!5--O <br /> -------------- ---------------- -------------- (Complete in Triplicate) <br />------ --- ------------------------- ed <br /> Date Issu -------------- --- <br /> This Permit Expires I Year From Date Issued <br /> ----------- -------- -- --- ---------------------- <br /> -d-r-install-th�e work herein <br /> Applicatiori is.hereby made to the Son Joaquin Local Health District for a permit to construct an <br /> described. This application made in compliance wit County Ordjp4nce N 549 and existing Rules and Regulations:., <br /> I I ft 2-, J7�-ew- <br /> �CENSUS TRACT ------------------------- <br /> JOB ADDRESS/LOCAlFi64-4/-./l-`.-�l:;/----- <br /> Owner's Name ... . .. r e -------0--------------------------------------------- ------.Phone —---------------------------------- <br /> ----------------------------- <br /> Address - -------- - ------- ------- ----------- -------- ------------ city ---------------------------------------------- <br /> License #�--7 <br /> Ile ------------------ Phone ------ <br /> Contra ctor's'Narne ----- --------------------- <br /> Installation will serve: Residence partment House,FJ Commercial :[-]Trailer Court ;E] <br /> MotelD Other -------------------------------------------- <br /> oms -2 <br /> Number of living units:---- ------ Number of b-Oro ---- -----Garbc!ge Grinder 4 5a' Jot Size �1,--."XI -- -------------------- <br /> Water Supply: Public System and name :_ ---- - ------- -----------------------------------------------------—---------Priivate E] <br /> r clay E],_-Peat E] Sandy Loam ,E] Clay-Loam '[] <br /> Character of soil to a depth of 3 feet. � and'E] <br /> Hardpan E] Adobe fElfill material <br /> if yes, type ---------------------------- <br /> {Plot plan,1Showing 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 permitted if public sewer is available within 200 feet,) <br /> Size_ ------------------------- <br /> S ---�-e-7— <br /> Y, --------------- ---- Liquid Depth <br /> PACKAGE TREATMENT SEPTIC TANKf <br /> Capacity Compartments ---------------------- <br /> Distance to nearest. Well —-——---------------Foundation - -------------------- <br /> Prop. Line ----------- <br /> - Z,;? ----- - <br /> LEACHING LINE No. of Lines" -- ----Length of eacO-inel Tot�l Length � ------------ <br /> 'D' Box Filter Material ---Depth Filter Material e Y-1- ------------•-------------- <br /> ------------- Property Line - ----------------- <br /> Distance to nearest: Well ------------------------ Foundation ----------- <br /> SEEPAGE PIT Depth Diameter ...... Number ----i5,�----------------- Roc,k Filled Yes,,ga---No <br /> ----------Rock Size --- o---------- 10 <br /> Water Table Depth ------ - --------------- <br /> " ) Line ............ <br /> -------------- <br /> Distance to'neareiit--Well --------- -----------------Foundation --- .. ...... Prol <br /> REPAIR/ADDITION(Prev. Sanitation Permit #----_y----------------------------------------- Date ------------------------------ <br /> Septic Tank (Specify Requirements) ---- -------------------- ----------------------------- - <br /> -------------------------- <br /> --------------------------------------------------- <br /> ------------ <br /> --------- --- --------- <br /> Disposal Field (Specify Requirements) <br /> ------------------------------------------ ------------ -------- ------ <br /> ------------------------------------------ ------------------- <br /> ---------------------- ----------- <br /> ------ ------------------------------------------------------------- -------------------------------- t 4 <br /> 4 1 <br /> ------- - ------------ <br /> ----------------------------------------------------------------------------- ------ <br /> --- - --------- ----------------- ------------------------------------------------------------- <br /> (Draw"existing and required addition on reverse side) <br /> at tl;'i work will be done in accordance with Son Joaquin <br /> I "hereby certify that I have prepdeed this application and that 1 ;1 . k .- � -�----� --, - I <br /> alth Distrit#t. Rome owner or licen- <br /> sed <br /> Ordinances, State Laws, aiAcl Rules and Regulations of th6-Sah JdacluWLocal-He C <br /> sed agents signature certifies the following: in.such manner <br /> certify that in the performance of the work for which this permit is issued, I shall not employ any person <br /> as to become subject to Workman S, ampinsation laws of California." <br /> Owner- <br /> Signed ------------------------------------- <br /> By ------------- ------- ------------------------------------- ---------- ---------------- <br /> Title ---------- <br /> (if other than ownerY. <br /> *, <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ... . ------- -- --------------------------------------------------------------------------- DATE <br /> ',-; DATE _--------------------•---------------------- <br /> A�-------1)------ <br /> ADDITIONAL COMMENTS <br /> BUILDING PERMIT ISSUED <br /> --- --------- <br /> ----------------------------- ----- -------- -------------------------- ------------- ------------------------------------------------------------- ---------- ---------------- <br /> ----------------------------- ---------------- I <br /> ----------------------------- <br /> -------------------- -------- ------------------- <br /> ---------------------------------- - ---------------- ---- -- ------------------------------------------- <br /> Date ----- - ------- -7v--------- <br /> Final Inspection by: ---------------- --------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4. <br /> E. H. 9 1-'68 Rev. 5M <br />