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FOR OFFICE USE- APPLICATIOWFOR SANITATION PERMIT ----------------------------- --------------------------- f, Permit (Complete in-Triplicate) k� ....................... ------------------------ This.Permit Expires I Year From Date Issued Date Issued ___._-______'._ L Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC YATIIPN ------ -- ---------------CENSUS TRACT ------------- Owner's Name -/Z ------ ---------------------------Phonp.--------- ------------------------ Address -------------- ------ - ------- -- - ----- city - ------- ----------------- ---------- Contractor's Name -------- ----------- ----- - ------------------ -----------Licenie # Installation will serve: Residence [❑ Apartment HouseF] Commerciale:E3*rWrer Court' 0 'Motel E]Other ----------------- ----- --------------- e Number of living units:--O----- Number of bedroom Garbc�ge Grinder ....In- Lot Size WaterSupply. Public System and name ----------- -------------------------------------;-----------------------------------•--------•---------------- ----------------------------------*-------------------------Private E] Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay El .Peat E] 1 Sandy Loom -E] Clay Loam,.0 Hardpan E) Adobe,rTV Fill Material ----- ------ If yes, type ---------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 4 NEW INSTALLATION: (N9.septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC K Size------- -%5-7�--i Liquid SANK Depth 4-1 Z-T—M-a t e- r i a I c,-11?-"o. Compartm ... Type - -, ents ----- Capacity - - �_____ Type to nearest: Well ------ _____________________Foundation -/0---- Prop. Line ..-"5 .... ........ i 10 \44 LEACHING LINE r Y No. of Lines -----10-----/---- Length of each line-----'9�--- Total Length ------------- 'D' Box Type Filter Material --- ------Depth Filter Material ------- .. ......I----------------------- ------- Foundation -------- Distance�tb nearest: Well -----6-V--- --- --- Property Line ......I.— t -, w-- , -- SEEPAGE PIT Depth ---- ------- Diameter Number ------/---------------- Rock Filled Yes S--,19-0 0 Water Table Depth ---- --- ------------------Rock Size ---/-/x----_-7--?---, - Distance ! nearest: Well ----/ to ----------------------------Foundation ._ Q__--.__-_ Prop. Line ------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _______________________________-__) i SepticTank (Specify Requirements) -------- ------------------------------------------------------------------------------------------------------t.------------------- I DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------I---- ------------------------------------- ----------------------------------------- ------------------------------------I------------- ---------- ---------- -------- -----------------------------------I----------------------------------------------------- -------------------------------------------------------------------------------------------- . I (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .... --------------------------------------- - ---- ------ ------ -------- Owner By --------------------------------------------------- ------------ ----------- Title ------e - --------------------------------------- (if other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED �BY --------------- DATE ---6------ rl.--t - -------------------------------------- BUILDING PERMIT ISSUED ------------ ---------- ----------/-------------------------------------------------------------------DATE ------------- ........ •-----..-_.......... ADDITIONALCOMMENTS ------------- ------------------------------------------------- ------ -------------------------------------------------------------------------------------- -------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- -------------------------------------------- ------------------------------------------------------------------------------ Final Inspection by-. -Date -------------------------------------------------------------- ----------------------------------- ----- ----- - -- e ------- J N JOAQUIN LOCAL HEALTH DISTRICT.,. E. H. 9 1-'68 Rev. 5M.