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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> A Permit No. <br /> --------- - ---------7=�5, 1 <br /> (Complete in Triplicate) <br /> ......................... <br /> ................... <br /> Date Issued <br /> This Permit Expi Is I Year From Date Issued <br /> .......... <br /> Application is hereby made to the Son Joaquin Local Health District for a permit <br /> mit to construct and install the work here-in <br /> described. This application is made in compliance with C. nty OrdinanceNo. 549 and existing Rules and Regulations: <br /> .................... <br /> ........CENSUS TRACT <br /> .1.4or ...... <br /> 7,33- 6�10*_ _16� ....... ............•••• <br /> _.-...._CENSUS ADDRESS/LOCATION ---------- <br /> Owner's Name -.. =-----•--•-••••.1.............. ....... I.................................--Phone ------------------------------ <br /> Address - Y_0474az4C/ ,----------_SA -----• City ---------------- -----------------------------•--••-J-•=-••_• -_ .- <br /> Contractor's Name-- .. .. -----------------'----q. i---- License # Phone . <br /> ... <br /> Installation will serve. Residence [Apartment Hbus,0 Commercial(3Traller Court [I <br /> Motel (7 Other --------------------_...................... ... <br /> Number of living units-___�---- Number of bedrooms Gorbc�ge Grinder Lot Size ..... <br /> ....... <br /> Water Supply: Public System and name-----------------•• •------------•-•-----_........------ ---------- Private <br /> y 0 <br /> Character of soil to a depth of 3 f6et`- Sand 0 Silt 0 1' Clay [-] Peat E] Sandy Loam ,[-] ClaLoom <br /> Hardpan ❑ Adobe-[E-Fill Material ------------ If yes,type ----------------_--------- <br /> (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION: lNo septic tank or seepage pit permitted <br /> mitted if public sewer is available within 200 feet,) 41- <br /> PACKAGE TREATMENT I I SEPTIC TANK'I ) , Size----- ---------- ------------------------------- Liquid Depth _.------------------------ VCapacity ---.•------------- Type ........i-------.... Material--- -------- ......... No. Compartments -_----------_-- -- <br /> Distance to nearest. Well ------- _ (k <br /> -------- _.._--_Foundation .... --------_------ Prop. Line --------­------------ tA. <br /> t ... _.._--_Foundation <br /> LEACHING LINE No. of Lines ------------------------ Length of each line-!------------------- Total Length ........................... <br /> 1 1. .. <br /> 'D' Box -----------. Type Filter Mat ial --------- _.---Depth Filter Materia( -_-------------- ................ .... <br /> - L ­ <br /> Distanceito nearest: Well ------------ ...... Foundation ------------------------ Property Line ------------_--------- <br /> SEEPAGE PIT ------------- Diameter A------------- Number .......... ----------------- Rock Filled Yes Q No q_J <br /> Water Table Depth ----------_-------I .........................Rock Size ----------------------------•--- <br /> Distance <br /> -----I------------------------- <br /> Distance to nearest-. Well ____....... I------------------­-­-Foundation ............ ....... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev, Sanitation Permit# ------------------- ----------------------- Date ........... --------------------) <br /> -----------­ ........... <br /> Septic Tank (Specify Requirements) ............... --------- I---------........._... ................ .............. -- <br /> Disposal Field (Specify. Requirements}'..%_/,P..A��----------- <br /> - ----------------­-.' .. <br /> ... <br /> ------------------ ------------------------------------- <br /> -----------1-------------------------------------------------------- ------------.-W-1�------------------------------------------------------------------ ----------••-----•- ----- ­----------- <br /> (Draw existing an re�uirecl addition on reverse side) - <br /> I hereby certify that I have prepared this application GAd that the work will be done in accordance with Son Joaquin <br /> i owner County Ordinances, State Laws, and Rules and Regulations of the. Son Joaquin Local Health District. Home wn or licen- <br /> sed <br /> cen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance;of the work for which i is permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws If California." <br /> Signed --------------*------------ 1---------_---- Owner <br /> 1--------------- -Title ----------__-------------------------------------------------------- <br /> Byof other than owner) <br /> FOR -DEPARTMENT USE ONLY <br /> _1 DATE ... _6- ----- <br /> APPLICATION ACCEPTED BY <br /> BUILDING PERMIT ISSUED __.------------------ DATE ...................................... <br /> ------------------- ------*---------------------------­-------*----------- <br /> ADDITIONALCOMMENTS -----•-----•-••--------------•-------------- --- ........................................................................................... ------­....... <br /> ------------------------------­........I.........ii................................................. -------­--------- ­------------- -----I . - .. ... <br /> ----------------- ---------------------------- --------------------_--- --------------111- ------------------------------------------------------------------------------- ........ ...... <br /> ........................ <br /> --------------­------ AV.... ----------------------- ---- ----_--------------- ----- ..... Date 2- <br /> - - -- ----- -1......................... ......._ ------ <br /> - - - ......... <br /> Final Inspection _011�---- - - ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 4 1-'68'Rev. "5M <br />