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FOR OFFICE USE: <br /> T 3 APPLICATION FOR SANITATION PERMIT <br /> ............ ................ 07- - �. Permit Nox,../ <br /> lComplete in Triplicate) <br />..........I...............................r............. <br /> Date <br /> ........ ....... ...............I........................ This Permit Expires I 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 Reg6lotions- <br /> Jor <br /> 8 ADDRESS/LOCATION ................. ...... ..... ... ...................... _CENSUS TRACT __.................... <br /> Owner's Name ................ .. ....I... hppe .................................... <br /> ,d .... ..............­*..........................*............ - 3 - <br /> Address .............. ------ ................................ ......city . ..... .................................................. <br /> ..... ...... <br /> Contractor's Name -------- ...................License Phone <br /> Installation will serve: Residence eWp_a_rtm­ent Housso Commercial OTraller Court 0 <br /> Motel []Other <br /> ..............**........ <br /> Number of living unius. Number of bedrooms Garbage Grind.. ..... Lot Size .. .. ... ........ . ........... <br /> Water Supply: Public System and name ..-•------------------•----........_.._._......----•--• 4"..-...........................---...............Private <br /> Character of soil to a depth of 3 feet. Sand t] Silt E3 Clay"0 Peat 0 Sandy Loom 0 Clay Loom <br /> Hardpan p Adobe(3-AllM6terial . <br /> If yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system In relatioti"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 --------------C..... Type ..................... Material....................... No. Compartments ...................... <br /> Distance.to nearest. Well ...... .......................Foundation .......... ........... Prop. Line ...................... <br /> LEACHING LINE, No. of Lines --------- Length of each line..........................­ Total Length .................__.....__-- <br /> 'D' <br /> ....... ...................'D' Box ......._ Type Filter Material ....................Depth Filter Material ....... ............................ <br /> Distance to nearest. Well ....... ...... Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT Depth .................... Diameter ................ Number ------_--------------_--- Rock. Filled Yes ❑ No 0 <br /> Water Table Depth'.-•-- -•--••......--•--• ........................Rock-S'ize .......................... <br /> Distance to nearest. Well ------------------------------••----....Foundation ........._......... Prop. Lin® ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ......................... <br /> ......... ------ <br /> Disposal Field ISpecify Requirements) <br /> Septic.-Tank (Specify. Requirements) ....... . ........ ... ...........----.....--------------•----• ------- <br /> "o' <br /> ............ ...... <br /> .......................4-,. ....... --------------------------------------------------------------------------------- ---------•-•--•-•--•---- <br /> •-----•--------•-----•-• <br /> ......................-----­----------------- ------- --------------------------------------------------------------- -----------------------------­- ..................*.................................................... <br /> {Draw existing and required addition on reverse side) % i <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 s4ub*ect to Workman's Compensation laws of California." <br /> Workman's <br /> Signed ---------- ------- ------------------------- ------------------------------------------ Owner <br /> By ------------ -------- Title <br /> Z---- - _11Zt!! ................ . ..........C�1� .................... <br /> of er-t ran owner) <br /> f9R DEPARTMENT USE ONLY - 4 <br /> APPLICATION ACCEPTED BY --------IV A --------_-- ...... .....� �­------------------------------- DATE_7/7e.7� -7 --------- <br /> BUILDINGPERMIT ISSUED --------------------C/--------- -------------------------- ----------------------- --DATE ..---------------------------------------- <br /> ADDITIONALCOMMENTS --------------------- ---•--- ----------­__........c---------------------------­ -.-...----.....----------------------------••-• . <br /> ..---------------------------------=- ---------------------------------------------------*---------------- -------- --------T----------------- ........----------- •------------- <br /> --------------------------------------------- --­-----------------------------------------------------------------------------------­*------------------------------ ------------------------- <br /> --------------- ------­-­---------- ---------------------------------- -------t............................................. 7 ...... <br /> Final Inspectidn by: -------------------------­-- .........................................................Date---.-.-. ...... <br /> EH 13 24 1-68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />