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_1=OR-OrAtt-USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. .. .......... <br /> (Complete In Triplicate) <br /> ................................... ..I . . . . -, I — '. . . .,. - - . . j 4-' <br /> ....... ................. This Permit Expires I Year From Date Issued Date Issue . .....j........ <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 maIn compliance with County Ordinance No. 549 and existing Rules and Regulationst <br /> JOB ADDRESS/LOCATION ...1....<.- ?. T_ (OF. <br /> ..............._...... ...........CENSUS TRACT _........................ <br /> Owner's Name • .....�(.............. .........I...........................Phone . _:..'`...�..� ........ <br /> (7 <br /> Address .................... .... ... C ity ---- <br /> ...... <br /> Contractor's Name - -------------- -------License ..... <br /> #G� 11,911.......Phone <br /> Installation will serve: Residence Apartment Houseo Commercial OTrailer Court 0 <br /> Motel [3 Other............................................. <br /> Number of living units:_._--- Number of bedrooms -----Garbage Grinder --------Lot Size ---------------- <br /> Water Supply.. Public System and name ................ .................-...............Private 0 <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay 0 Peat 0 Sandy Loam C] Clay Loam 0 <br /> Hardpan 0 Aclobe:g3--'Fill Material ............ If yes,type ............... ............ <br /> (Plot plan, showing size of lot, loc I ation 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 /> PACKAGE TREATMENT SEPTIC TANK Size--------- ......................... ............ Liquid Depth ................. ....... . <br /> Capacity --------------•- Type .................... Material...................... No. Compartments ---•--......: ;r <br /> Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line _...------------------ <br /> LEACHING LINE No. of lines _--------------- ------ Length of each line.-..:__......_.............. Total Length ............................ <br /> 'D' Sox_..:-........ Type Filter Material ..............'_....Depth Filter Material .................................._....... <br /> Distance-to nearest. Well -------_--- .......... Foundation ... .................... Property Line ........................ <br /> Diameter ................ Number ......... Rock Filled Yes ❑ N <br /> SEEPAGE PIT Depth As._.._}.._..._...:_ a U <br /> Water Table Depth .............. ........ ........... ............Rock Size -------- ....... ........... <br /> r <br /> Distance ............. <br /> to nearest- Well ------------ .................... ----Foundation _------------------ Proo. Line --------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........................•.._----.------.---- Date ....,....---------.-._.._.-.:----_I <br /> Septic Tank (Specify Requirements) ......... _................ ....... ................. <br /> --------------------- ---- ......... ------ <br /> _!�......... <br /> Disposal Field (Specify Requirements) --- <br /> ------------------------------------- ........................................................................................... ............................I----------------------- <br /> I <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------........ <br /> • '(Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepa4cl 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. Home owner or licen. <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work far which this permit Is Issued, I shot] not employ any.person In such manner <br /> as to become subject to Workman's'Compensation laws of California." <br /> Signed ...... .. ... ........ .... ....... ................................. .... Owner <br /> By - ­------------------- title <br /> Jlf other than nerl <br /> FOR DEPARTMENT USE ONLY, <br /> APPLICATION ACCEPTED BY ......................... ------------ DATE --------- ------- <br /> BUILDING PERMIT ISSUED ....... <br /> ------------------------- ­ ------_------------ --------------------DATE ------------------------------ ------------ <br /> ADDITIONALCOMMENTS -----­­ I -._1....I........ ................I...........................................................1-1....... .........­ <br /> ------------ •-•------------ ......................I...........................­­­­.........1-1-1...... ...... ------ <br /> ------------------•----•--------._.....-...------------...................----------••-•--••---......-'---•....-........................ ...........------------.......................:_...._....-------•- <br /> -- <br /> -------- ----------------1------- ......­­------I.......... --------------------------------------------- 102 --------- <br /> finalInspection by- ------------------ ---------•-=-------------......._........---.----------. . Date --------- ......... <br /> E:H 13 2h 1-b9 Rev. 5m SAN JOAQUIN LOCAL HEALTH DI CT 8/74 311 <br />