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FOR OFFICE USE- <br /> j�APPLICATION FOR SANITATION PERMIT <br /> --------7-------------------------------- --------------- "_1(6_0' M­2_PIete in Triplicate) Permit No. <br /> ------------------------------------------------ <br /> Th is <br /> ------------------------------------:--------------- Permit Expires I Year From Date Issued 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 Reg tions: <br /> . .. ....... 6 _------------------------------------------._CENSUS TRACT ---- -- ------- <br /> JOB ADDRESS/LOCATION. --------------- <br /> Owners Name N/V I----- ------- ------------------------- <br /> j,4A2_ j...... ------------------------------- ----- -------Phone <br /> Address ------------- --4; ----------------- City ------ --------------------------------------------- <br /> ---------------------------------------------- <br /> Contractor's Name ----------License # ------------------------- Phone ---------------------------- <br /> Installation will serve- ;'Residence gApartment House-E] Commercial :E]Trailer Court C] <br /> ...................... <br /> Motel F-1 Other <br /> ------- ----------- <br /> Number of living units: ------ Number of bedrooms --a-----Garba-ge-'Grinder-------------- Lot Size --------_--- <br /> Water Supply: Public System and name ajy- <br /> --------- ----------------------------- -------------------------------------------------Private <br /> Character of soil to a depth of 3 feet.. Sand'E] Silt❑ Clay Ej Peat F] Sandy Loam E] Clay Loam E] <br /> Hardpan E] Adobe Fill Material ------------ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot,i�location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> .I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) eor <br /> PACKAGE TREATMENT SEPTIC TANK Ag Size------/;?-0 -------- ---_ Liquid,Depth ____411-________,_-__- <br /> Capacityp <br /> i - <br /> Type _t9br, l. Material--- ------� No. Compartments -,Z------ <br /> Distancek to nearest: Well ----------------------------------- Foundation ___14 f----------- Prop. Line -------5-------------- <br /> LEACHING LINE No. of Dines --------------- Length of each line-_______ ( .___..______ Total Length -------------- <br /> ' 'D' <br /> --------1- <br /> 'D' Box <br /> Type Filter Material -.Depth Filter 10terial -------Z?-------------------7---------- <br /> Distance�to nearest. Well ------—--------------- Foundation ----- ----------------- Property Line. ------ <br /> !6 1� I? <br /> SEEPAGE PIT Depth -'Im:?,_.S--------- Diameter ___33_____ Number _-__._-__l---------------- Rock filled Yes Vf No C] <br /> o Water Table Depth -------------------------------------•------Rock Size ------el-.� --------------- <br /> Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line ----------•---•-----•- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> SepticTank (Specify Requirements) -------- ------------------------------------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requi rements) ----------------------------------------------------------------------------------------------------------------------I--------------- <br /> --------------------------------- - -------------------------------------------------------------------------- ------------- ------------------------------------------------------ <br /> ----------------------------------------------------- ----------------------------------------------------------------------------------------------------- --------------------------- <br /> �� fDraw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will he done in accordance with Son Joaquin <br /> County Ordinances, State Laws, :and Rules and Regulations of the San 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 byec Vmes jec to Workmahl�'s nCpjen5 .on Ila f California." <br /> _12 <br /> ----- - -- ----------- <br /> Signed" - ---- ------- ----------- Owner <br /> By -------- ------- ------ Title ------------------------------------------------------------------------ <br /> ------ - ----- --------------------------------- <br /> other than ow <br /> )!6R DEPARTMENT USE ONLY <br /> _Zj_aAPPLICATION- ACCEPTED BY ------------------------.----------------------------------------------------------- DATE -----0_-_/0_J._-- __------------ <br /> BUILDING PERMIT ISSUED ---------- ----------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> DDITIONAL C07 1--A ----------------------------I------ ------ <br /> 9?UE��Z--- - ----------------------- ----------- ----------f`5�-------------- <br /> -- -------- ---W!- ----- - . ...... <br /> V-IC <br /> ------------------------------------------------------------------------------------------ <br /> ----------- ---------------- -- -- ----------------------------------------------------------------------------------------------- --------------------------- <br /> FinalInspection by; ------- - ---- -- - ---------------------------------------------------------------------------Date --------------- <br /> "' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> V68 Re 5M. <br />