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%R"Coe USE: <br /> ...........................7-.. ... APPLICATION FOR SANITATION PERMIT <br /> """""'• <br /> ................ .. .... . . ......... (Complete in Triplicate) Permit No. 6 <br /> ------------ <br /> .. . .. ....................... This Permit Expires I Year From Date Issued e Issued <br /> APPIlou"on Is hereby mods,to the Son Joaquin Local Health District for a permit to cons <br /> described. This application Is made in compliance with construct and install the work herein <br /> nty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOCATION "Fu <br /> Owner's Name .............. ........ - CENSUS TRACT <br /> ....................T....................... .........I <br /> Address ............... ;� '3-V-1 I ..Phone <br /> ........... .... Re....... .Contractor's Name ........ . ....... city ...... ...........-----License # 221-UJInstcillation will serve. ..- Phonst ...sidence G3,ApiTrtrnW#House 0 Commercial oTrallor Court ................ <br /> Number of living units: Motel 0 Other......... <br /> �/- - Number of bedrooms Lr��'r b- g-e- Grinder---, Lot Size <br /> Water Supply; Public System and name ....... ......................... .................. ..................... ....................—PrIvate <br /> Character of soil to a depth of 3 feet: Sand 0 silt 0 Cloy 0 Peat Sandy Loom C3 Cley Lam []!�-w <br /> Hardpan El Ad Fill M6terial /./2//,) <br /> (Plot plan, showing size of lot, location <br /> .... .. If yes,type-............ ............ <br /> ocation of system in/I relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEWW"ALLATWNt (No septic tank of seepage pit permitted if public sewer Is available within 200 feet,) <br /> PACKAGE TREATMENT f I SEPTIC TANK f <br /> Capadly ...... Size......----------------------------------------- Liquid Depth ................. P <br /> ........... Type - -------- -- --- Material---------------------- No. Compartments <br /> - Well .... <br /> Distance to nearest. <br /> LEACHING LINE ------------------Foundation .............__.... Prop. Line <br /> No. of Lines ........................ Length of each line..-..-....__._.... Total Length ......... ....... <br /> ..­*---------- <br /> 'D' Box ......--_ Type Filter Material ....................Depth Filter Material ......................... <br /> Distance to nearest: Well Foundation .. . ........ . Property Line <br /> ...................-*-", -4 <br /> SEEPAGE PITDepth -------------------- Diameter ...... ......... Number .. ...... ... ------------ Rock Filled Yes 13 No <br /> Water Table Depth ................................................Rock Size ...................... <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ................... <br /> KPAIRADDITION(Prev. Sanitation Permit# ----------------- . ... .. Date 11-1-1-11------- <br /> YC............ .......� <br /> Septic Tank (Specify Requirements) .... <br /> -4z . ....... ... .......... .. .. ............... <br /> Disposal Field (Specify Requirements) <br /> ---------------------------------1-------------------- <br /> ...................... ----------------------- ................................-1.......................................................................................... ............... <br /> ............ ............... ......... ........ I 11__......11 --------- .............................................1-.......................................... .............. <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, 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 for which this permit is Issued, I shall not employ any person in such manner <br /> as to become subject to Workman's CWompensotio aws of California." <br /> . ......... <br /> Signed . ............ ...... ............ Owner <br /> By ..... . . . ............................ Title --- ..... ..... ... ------- . ... <br /> `if n owner) <br /> 0 ARTMENT E ONLY <br /> APPLICATION ACCEPTED BY -... . .. ............... ....... .............. ............. DATE ... <br /> B <br /> BUILDING PERMIT ISSUED _�, ; <br /> ADDITIONAL COMMENTS <br /> ................. ..... .. ..... .................................. ... ..... ............... ............... <br /> ................. .... .. -- - - - - -------------------*- --- ------- --- ................................................ <br /> .................... --- ------ <br /> final Inspection by: .. . . <br /> ------------- ........Date ................. ................. <br /> if 13 211 1-68 &v. 5m SAN JOAQ�WN LOCAL HEALTH DISTRICT 8/7h 3M C13 <br />