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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. .......... <br /> ........ .......... ..........-1........ .......... (Complete in Triplicate) <br /> issued 16 <br /> ...... . <br /> ............ ............. ................ Year From Dote Issued Date ........-......... <br /> This Permit Expires 1,Y <br /> 'Applica.tio-n-is hereby made to thelSon Joaquin Local Hecilth District for a permit <br /> 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 /> • N �cL 3 ........ ............. .........CENSUS TRACT <br /> JOB AOwner'DDRESS/LOCATIO <br /> . ...............Phone <br /> ................ ...... <br /> ......... City ... ...... <br /> Address .... ............. ................ <br /> 1.... €--. License # ..... Phoned.q. <br /> Contractor's Name 0_1 r.- <br /> Installation will serve. Residence Apartment House,(:] Commercial oTraiter Court 0 <br /> -Motel []Other .........................I...-••------....... <br /> 4,C-PUR .............. <br /> Limber of living 'Num: bee of bedrboms arba'ge Grinder ............ Lot Size ... <br /> N _G <br /> .......Private Q0, <br /> Water Supply: Public System and name .....-...... ........ ------- ........ ...... .................. ............. <br /> Ch I aracter of soil to a depth of 3feet..- x Sand r Silt 0 Cloy."[j t'_' Peat 0 Sandy Loomg Clay Loam 0 <br /> Hardpan ❑ Adobe ❑ Fill Material ............ if yes,type I---------_-------------- <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,) <br /> SEPTIC TAN.K.-t -r,. Size...................... ......... ---- Liquid Depth ...... .................... <br /> PACKAGE TREATMENT, .( ...... No. Compartme.mens ............ <br /> Material.............. <br /> Capacity ..................... Type .......I......... <br /> Di.stance to' nearest: Well- -------_------�­..................Foundation ............ ......... Prop. Line ....................... <br /> LEACHING LINE No. of Lines- ----------------- Length of each line... .......................... Total Length ........................... <br /> V 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 Q <br /> e ....... ......-.......... <br /> Water Table Depth --------__1--------- .............&........Rock S4 <br /> Distance to nearest: Well ........................ Foundation ---_-------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................. ......... Dote ............................. J, <br /> ...........---••........................------7.......-........ <br /> Septic Tank (Specify Requirements) ...........I................. ........... ------- .......... <br /> Disposal Field (Specify Requirements) -_------------ ........---•--•-------------------- .............. .............. ............ <br /> ----------- ............................. <br /> ----------­---- 'fro --------------------------------- ........ ........ <br /> J................................. ------ ...... <br /> ........ ....- <br /> ................... ........ ----------- -------------- <br /> (Draw existing and required addition on reverse side <br /> I herebycertify that I have this application and that 'the work Will be done .in accordance with Son Joaquin <br /> owner or licen- <br /> County Ordinances, State Laws,.and Rules and Regulations of the Son Joaquin Local Health District. Home <br /> sed agents`signature certifies the following- not employ any person in such manner <br /> "I certify�lhat in the performanc4 of the work for which this permit is issued, I shall <br /> as to becbme subject to Workman's Compensation laws of California." <br /> Signed _ -r..... <br /> . ........ Owner <br /> -------------------------------- <br /> By 4 ............ ..... ....... .... <br /> .................... <br /> itle <br /> ............................ <br /> (If other than owner) <br /> F9 <br /> DEPARTMENT USE ONLY <br /> TE ......... <br /> DA <br /> APPLICATION ACCEPTED BY ....' . ..................I................... ......... <br /> BUILDING PERMIT ISSUED ..;----- _- ........................ ..........................................DATE ........................................... <br /> . ........... .............. <br /> i .. ....... .. ---------­-­--------- ........................a...... <br /> ADDITIONALCOMMENTS ..:............ ................................. ........ ........ <br /> ................... ............. ....... ;......I............. .................... <br /> ................... ................ ...........;................... .............. ............. ............. <br /> ....................­.............-1....................... ....... .......... <br /> ...........V­..:............. .............................. ..................... ...........­.......... ........ ..................... <br /> ........... ................ Date ;.......1..5.... <br /> I—.......... <br /> ... <br /> Final Inspection by. ............. ........ ... .... <br /> —'SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> 7/723 M <br />