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FOR OFFICE Ur2- <br /> APPLICATION FOR SANITATION PERMIT <br /> ............................................... . <br /> Permit NO. . <br /> ..........I................I................ ...... (Complete in Triplicate) .... ........ <br /> " <br /> ............................. This Permit Expires I Year from Date Issued <br /> Date issued <br /> Application is hereby made to the Son Joaquin Local Health District for a per'mit 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 /> JOB ADDRESS/LOCATIPN ........................CENSUS TRACT .... -------- <br /> Owner's Name -4 _. Z------ .. .......... ............................... .4.. ..................PhoneF <br /> Address Zo •/F/ ., Af !Fe-Al..._ ...-- city.. ...... - .. ..Contractor's Name ........(�r --- -------------------L........License# --:----------------------- Phone <br /> Installation will serve- Residence f3 Apartment House E] Commercial ]Trailer Court 0 <br /> Motel []Other....... ..................................... <br /> Number of living units...___)----- Number of bedrooms -2-....Gorbage Grinder .......... Lot Size ................................ <br /> Water Supply. Public System and name ..................................... -------------__............................ ............. ...Private <br /> Character of soil to a depth of 3 feet: Sand Iff Silt 0 Clay 0 Peat 0 Sandy Loom 0 Clay Loam'o <br /> Hardpan 0 Adobe E3 Fill M6terIol ............ 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 permitted If public sewer Is available within 200 feet,) ZF <br /> PACKAGE TREATMENT SEPTIC TANK; -------------- .........................•........ Liquid Depth -------------------- <br /> Capacity ---I--------I........ Type ... Mat 101............. ......... No. Compartments .......................�r <br /> Distance. to nearest: Well .......................... ........Foun Lion ...................... Prop. Line ...... <br /> ............ <br /> LEACHING LINE No. of Lines ........................ Length of e line--____ ..................... Total Length -------------L.............. <br /> 'D' BOX ... ... Type Filter Material .... ... pth Filter Material ......._............._.._...__._._-.........LA. <br /> Distance to nearest: Well ........... .... Founds on ........................ Property Line ....•.................. <br /> _.,.n t e Le <br /> ngth a f Le th .e-M F <br /> c 0 <br /> 0 h u u <br /> t t n- <br /> d <br /> n <br /> __ <br /> ______Foun.0-u <br /> rh <br /> n t <br /> D P, Fit on ....... <br /> e u <br /> um m <br /> r/ I r ............ <br /> SEEPAGE PIT, Depth --------------------- Diameter ......... Num or ............................ Rock Filled Yes ❑ No 1� <br /> Water Table Depth .......................•................ ......Rock size -1............................ <br /> Distance to nearest. Well ........ ..............................Foundation .................... Prop. Line .... .................P <br /> REPAIRADDITIONIPrev. Sanitation Permit* ......... . ....................... ..... <br /> ... ............................... Date ...6......................... <br /> Septic Tank (Specify Requirements)-............. ....... ......... .............. ............ ......... ............. <br /> W-------------- -------------- . . .... <br /> Disposal Field (Specify Requirements) ... . ...... .. ...... r <br /> ..............---------------------------------------- .......................... ............. ......-............. -------------...........................I.................. <br /> --------------------------------------------------- ---------------- -------------------------------**------------------------------------------------- ............................. <br /> IDraw 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, and Rules and Regulations of the San Joaquin Local Health,,District. Home owner or licen- <br /> sed agents signature certifies the following- ­J <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 Wp*man's Compens tion laws of California." <br /> Signed -------- - ;-- -- --------I--- ----- ------ .........I------------ Owner <br /> -A---- <br /> By ---------- --a ----------.1--------- -------------------------- Sitle - ------------- ------------ ............. ...................4 <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....../ --------- ---- -- --------- ---- ............ ----------------------------- DATE --------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ­_­.................................. <br /> ADDITIONALCOMMENTS ....--------- ...... --------------------------------....... ------------------.....--...... ..............................................--- <br /> --------------------- ----------------- ------------------I------------------------------- -----------*------------------------------------------------------ <br /> -------------------- ......... ....................... ---------------- ---------------- ..........6.......................................................................... --------------------------- <br /> --------------------4--------------------- <br /> ...................... ...... ----------------*.............. ............ <br /> Final Inspection by. ... ...... ................................. ------ .................. ...Oate .. -..._.....----- <br /> EH 13 2b 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 6/7h 3M <br />