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FOR OFFICE USE- <br /> 7 Z2�1-- APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Triplicate) <br /> ----------I---------- <br /> ------------------------------ --------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to th6 Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is rVaUe in compliance with County Ordinance No. 549 and existing l les and Regulations. <br /> e07 <br /> JOB ADDRESS/I­O�CA�Tl;N ____CENSUS TRACT --------------------------- <br /> Owner's Name ----- -- - -- JI-------vi----------------------------------------------------------------- -------------------Phone ------------------------------------ <br /> Address ----------- r--4?17, ----------------Z------------------------------------------------- city -s-yt?a--*-- ----------------------------------- <br /> Contractor's Name .... —----------------------­,--------License # Phone ------------------------------ <br /> Installation will serve: Residence Ne Apartment House,[-] Cornmerciol :E]Trailer Court ;E] <br /> Motel 7 Other --------------------- ---------------------- <br /> ' Number of living units:---/--.-- Number of bedrooms -0-------Garbage GrinderAl-vo-- Lot Size --------------- <br /> Water Supply: Public System and name -------------------------------------------------------------- ------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay E] Peat❑ Sandy Loam -E] Clay,Loam.0 <br /> Hardpan E] Adobe [:] Fill Material ------------ If yes, type ---------------------------- <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 feetJ <br /> PACKAGE TREATMENT SEPTIC TANK:' Size---------------------------------------- Liquid Depth _--_-------_----__-----_--_ <br /> Capacity ------------- ------- Type -------------------- Material---------------------- No. Compartments -------------- ........ <br /> Distance to nearest.. Well ------------------------------------Foundation ----------------------- Prop. Line ----------------...... <br /> LEACHING LINE No. of Lines ------------------------ Length of each line-----.----------------------_ Total Length ----------------------------- <br /> 'D' Box------------- Type Filter Material --------------------Depth Filter Material -------------_---__-.--____-_-______--.-_.- <br /> t <br /> ( Distance <br /> ------------- ----------------------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line- ------------------------- <br /> SEEPAGE PIT Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes E] No 0 <br /> WaterTable Depth --------------------------------------- --------Rock Size -------------------------------- <br /> Distance to nearest; Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------- ----------- Date ---------------------------------- <br /> Septic Tank (Specify Requirements) --------------------- ---------- <br /> --------- <br /> D - <br /> .01 X-------- ---------- ------- <br /> is ements) ---- J------ ------ -----------F--- -------- <br /> . sal Field (Specify -------- <br /> ------------------------------------------------------------------------------------P ----------------- <br /> --- . ........ <br /> ----------------------------------------------------------- ------------------------------------------------I--------------------------------------------------------------------------------------------- <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 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 become subject to Workman's pensation laws of California." <br /> Signed ----­--- ----- -------------------------- ---- --------------------------------------------- Owner <br /> By ---r------------- --- - -------- -------------------------------------- Title ------&-411*4p ----------------------------------------- <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------- --------- --------------------------------------------------- DATE <br /> BUiLDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS------------------- ----------------- - --------------------------- ----- ---------------------------- -------- <br /> ------------------------------- - ------ <br /> 7------------------------------------------- W-- --- - - ------- k)-iV----------- <br /> --------------------------------------------------------------------------------------------------------------------------------------- ------I-A-------------------------- <br /> ------------------- --------------------4we-----W-----------------------------------------------------------------------------------------Date--- ------- <br /> Final Inspection by: ---------------------------N- - - Dat <br /> ------------------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />