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FOR QFFICE USE: <br /> Oy))/�//APPLICATION FOR SANITATION PERMIT 17 <br /> Permit No. <br /> ............... ................ ....... (Complete In Triplicate) <br />................................................. Date Issued A-2, 7 <br /> t.This?ormit.ExpIris,1 Your From-Date Issued <br /> .......................-.......... <br /> Application is hereby made to the Son Joaquin Local Health District for a per"mit to construct and,install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and exi;fIn4161es and Regulations: <br /> . <br /> .......................... .CENSUS TRACT ......:..........:.....•........... <br /> JOB ADDRESS/LOCATION ........ <br /> a '' d................................Phone .................................... <br /> Owner's Name ........ ...................... ........ <br /> Z <br /> Address .......... ............... ...... ..... ................................... city 551e�.60!1101�rl............................................... <br /> .ev -:;w--Jr � License # Phone <br /> Contractor's Name ---- .................... <br /> Installation will serve. Residence rkApartment House 0 Commercial.[3Traller Court 0 <br /> Motel0 Other ............................................ <br /> ................ <br /> Number of li'ving units:.../.-..- Number of bedrooms ...Garbage Grinder /j/9... Lot Size <br /> - :�. Private 0 <br /> ........ . Priv t <br /> ..................... <br /> Water Supply: Public System and name ...4.,gf <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay 0 Peat E] 'Sandy Loom 0 Cloy Loam 0 <br /> Har.dpan ❑ Adobe ' Fill Material ............ If yes,type ............................ N� <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 2.00 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK I I Size................................................ Liquid Depth ...............I <br /> Capacity ..................- Type .................... Material...................... No. Compartments ...................... <br /> Distance to nearest Well .Foundation .. . ... Prop. Line <br /> ........ ........... m;........................ <br /> Length ...... ............... <br /> ....... Length of each line.................. Total Long ... <br /> LEACHING.LINE No. of Lines .......... ...... k <br /> V Box ............ Type Filter Material ....................Depth Filter Material ........................................ <br /> Distance to nearest: Well ----------- Property Line ........................ <br /> .:,Foundation ........................ <br /> SEEPAGE PIT Depth .................... Diameter ................ Number ....................... Rack Filled Yes 0 No C3 <br /> Water Tabl-e-Depth­'........ ...........Rock Size ...........I...........` <br /> I - Lino ...................... <br /> Distance to-nearest.-Wellj......................................Foundation ............ Prop. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........... Date .................................. <br /> P, <br /> .......... <br /> Septic Tank (Specify Requirements), <br /> .................................................. ....... ......... <br /> Disposal Field (Specify Requirements) .......... ........................................ <br /> ... ....... <br /> ..................................................................... ............................................................................ ............ <br /> ...........................................................r-.........I............................ <br /> . .... .. ... . ... ....... ... <br /> ........................ ............11...........(. .......Draw-existing. -- ..a.rid..required addition on reverse side) <br /> I hereby certify that I have prepared this application c.ind 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 Of lic@"- <br /> sod agents signature certifies the follow'Ing: <br /> "I certify that in the performance of the work for which this permit is Issued, I shall not OMPIOY any person In such manner <br /> as to become sublact to Woirkman's CO'imp'6nsaklon laws-ofLCalifornic," <br /> Signed .......................... .. ........ -------- .......­­­................. Owner <br /> ........... .Title Title ��dvewlol.�..... ............... ............. ...... <br /> By .............................. . <br /> (if ot?-han owner) <br /> #0 PARTMENT USE ONLY <br /> ...... Z..y..... <br /> Z <br /> APPLICATION ACCEPTED BY <br /> DATE--_-:.... .... .. ..... .................................... ............. ...... <br /> .:..............DATE ................. .......................... <br /> BUILDING PERMIT ISSUED .............. .......................... ....:......... .._--•---; <br /> ...... ......I...... .......................................... ......... <br /> .......... <br /> .. . ........................ <br /> ... .......... <br /> ADDITIONAL COMMENTS .................... ................... <br /> ...... •-----....................._............ ...... <br /> .......... .................................j............................................. ............I ............. .. <br /> .............. ............ ...................... <br /> ..............................L................I.... . .. .. <br /> ...............I................... <br /> Ir .. ­­ ........................................6..t....... .. ................... <br /> Final Inspection by: ........................................ at& .... <br /> ..................... <br /> SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> c u 13 24 1_-AA o.. -qm 1/723_�[ <br />