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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No. .2.�`_V- <br />.......... ....•--------..........-_._­ ................. lComplete in Triplicate) <br />................................ ..._.....I.....-- .............. . . 16ot6 Issued <br /> ...........................I....... This Penult Expires I Year From Date Issued <br /> Applicati6n it hereby made to the Son Joaquin Local Health District for a permit to construct and Install the work herein i <br /> described.- This-application is made in compliance with County Ordinance No'i'549 and existing Rules and Regulations- <br /> JOB ADDRESS/LOCATION ....... CENSUS TRACT ......... .............. <br /> ............ . . . ................. <br /> Owner's Name ...... .D2...... ......................_.......... ...........—.......... ........ ......Phone .P3_4ZA <br /> .......................... <br /> ie .......... <br /> Address .. ...._............ .......... ........ city <br /> c;�93/9 ..... Phone C75....... <br /> V ...........................LicensJ # .... <br /> Contractor's Name .------- 4 _ ----- .......... <br /> Installation will serve: Residence []Apartment Housei—] Commercial E(frailer Court 0 <br /> Motel E]Other .........................................• <br /> Number of living units:.....__ .4-3. <br /> Number of bedrooms ..--Garbage Grinder! Lot Size ..................... ....................... <br /> ............. <br /> Water Supply. Public System and name ................................................................ ..........................................Prlvatelg� <br /> Character of soil to a depth of 3 feet. Sand E]- Silt 0 Clay 0 Peat U. Sandy Loam 0 Clay Loam 0 <br /> Hardpan[J Adobe 0 Fill Material .......1.....14..... If Yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse 5 e. <br /> I ll <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer Is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I I Size__.......... ................. Liquid Depth ................­1------ <br /> ---------- .--* ; <br /> _JII ..... _---- No. Compartments ....0 <br /> Capacity -------------------- Type ------ ............. Ma rial.. nts .................. NO <br /> Distance to nearest: Well ....... ................. ..........Foun. tion ...................... Prop. Line ....................... <br /> Total Length ....................4......�0 <br /> LEACHINGLINE No. of Lines ...... ------_-------- Length of ch line..- --:p........... <br /> 'D' Box ...... Type Fitter Material . ................ th Filter Material ............... ......... ................ <br /> "Ma <br /> F <br /> 0_u-n <br /> tion <br /> Material <br /> ------- --- <br /> ach <br /> Filter <br /> e h F10I ei <br /> Of <br /> a e 10 t <br /> p <br /> Distance to nearest. Well ----------- ... ... Fou ation .................. Property Line ........................ <br /> m or <br /> er _ __11--- ----- yes 0 No (3 <br /> Depth ......I . . ..... <br /> SEEPAGE PIT -------------. Diameter -- ------------- mber .....I........................ Rock Filled i- <br /> Water <br /> .... _R=k Size <br /> Water Table Depth ......... ...... ............Rock Size ..................... <br /> ...... ..... ...... <br /> ou at! <br /> F nd n <br /> Distance to nearest. Well --_---------------­. ..... --------Foury'I lation ----_-------_--- Prop. Line ....... ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............ --------------------- ------ Date I............................. <br /> ................. ....... <br /> Septic Tank (Specify Requirements) _------_-- ------- <br /> Disposal Fi6ld (Specify Require ents ... <br /> ----------- --7122........... ........... ---_--------------- _---- � <br /> ---------- <br /> __------------ -------- ------------ ---------------------- --------- ---- <br /> -------- .....................­­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 HOW&District. Home owner or licen- <br /> sed agents signature certifies the following: !1 <br /> "I certify that in the performance of the work for which this permit Is issued, 1shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws L f California." <br /> laws <br /> r <br /> �7 0A <br /> Signed ----- - ----- ------------ ---------- ---Z............. Owner <br /> ............... <br /> -------------------•--•--•------- Title ----------- --------------------- ­ ----------------- ------------ <br /> By ................ _P ... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY !I <br /> ----------------------- ............ <br /> APPLICATION ACCEPTED BY -------_ DATE <br /> BUILDING PERMIT ISSUED <br /> 1'�----- --------- ...�DATE ..................­................. <br /> ----------- <br /> ADDITIONALCOMMENTS -------------!------_1­1----------------------------------- ----------- --------11............... ---•---------- -- :............... -------------- ......... <br /> ........im ................................. <br /> .............. ... ...... ......... --------- --- <br /> ..................................... <br /> 7 ---- -- ---- -------------- --------------- ------------------- <br /> - ------- -----r------------------ --- -- ----------------_------------- - ...... ................ ti. . , . <br /> finalInspection by: A . ..... ................I . ..............................i....­­.............Date ........ ........ <br /> EH 13 2h 1-6 V. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />