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FOR OFFICE USE: l: .... ............ ------------- - _-------------- ------------------- , .- ------ - ------- -I--- ---- J[ --- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) This Permit Expires I Year From Date Issued Permit No. Date Issued ----------------- h Application is hereby made to the Son Joaquin Local Health District for 0 permit to construct and install the work erein described. This applicatio'h is made in compliance with County grdinance 0. and existing Rules and Regulations: JOB ADDRESS/L ATI ----- -- --- ----- CENSUS TRACT .......................... . .......... 1__- Ph ---------------------- ------------ Owner's Name ... .. .... Address - ------------ city ------- ............................... .1A --- �4(1, -�-_ Contractor's Name ..... ....... ---------------- - ----------- ............. ---------- License # -------- ------- ----- Phone ----- ---------------------- Installation will serve: Residence[] Apartment*House El Commercial:E]Trai'ler Court 0 - Motel C Other ------ -- G - a - r - --------- bc�ge Lot Size - ------------ Number of living, units-. ---- Number of bedrooms -0 II-._- Private El Water Supply: Public System and name ---------- ----------- --------- -- --------- ------_------------ p Character of soil to a depth of 3 feet: Sand 0 Silt [_1 Clay E] Peat El Sandy Loom Ft Clay Loam 0 IIHardpan F Adobe F Fill Material ------------ If yes, type . ----------_-------------- (Plot plan, showing size) of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: No septic tank or seepage pit permitted if qublic sewer is available within 200 feet) 1 Al Y2�_ 3— Liquid Depth - ---- ------- PACKAGE TREATMENT SEPTIC TANK} Size.. . -- -------- -------- .---....-- O Capacity %2-!1U ------- Type 10 .. ------ Material No. Compartments -----_----- d Distance to nearest. Well ---- -------------------- Foundation __.1-4 - ------------ Prop. Line --- ----- i .......... p Length ./ . ............ Lines ---------- Length of each line .... S_ --------- Total LEACHING LINE Or No. of 11 ----------------- Type V Box Filter Material AY ---- -- Depth Filter Material ------- -------- i Line ......... I ------ Distance to nearest: Well _rr-3 - ...... Foundation _N _ ------------ Property SEEPAGE PIT Depth ------- Diameter 3_3 ------- .Number -_ ---- ----- Rock Filled Yes No 10 !1 - 11 Water Table Depth Y-10 -------- ........ ---------- Rock Size Zyq --- Water Table VIV _f ---- Prop. --- ------------- - Distance to nearest: Well ---------------------- Foundation Line REPAIR/ADDITION (Prev.'I ---- -----_------- ------------------ Sanitotion Permit _ --- --------------- -------- 11 ----------- Septic Tank (Specify Requirements) ----- __ ------------ --------- _ ----------- ------ ---------- ...... ----------- . ........... Disposal Field (Specify Requirements) - ----- .............................. ................. ---------- ........................ ........ ------------- ------------- I -- ---- ----- . ..... ..................... ------------- .................. I ........... ............ ------------ ---------- -------------- -- --------- -------- ------------- - ------ - ------------ . . ........... ............... --------------- (Draw existing and required addition on reverse'side) with San Joaquin I hereby certify that I hl�ve prepared this application and that the work will be dome in accordance ri County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. 'Home owner or licen- sed agents signature certifies the following. - "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to . Workman's Compensation laws of California." Signed.... . ..... . e �/) , -------------- --- --- -------- Owner By-------------- ---- ---------11 ---------- ------------------ - --------------- ------------ Title - -- ------------- - ---- I ----------- ------------- ............ (if other th'an owner) FOR DEPARTMENT USE ONLY ......... DATE 47 41 ----------- APPLICATION ACCEPTED BY BUILDING PERMIT ISSUED . .... .............. ------------------- ------------_-_-- -------------................. ..-DATE --------------- ------------- ---- ADDITIONALCOMMENTS ...... ------------------------------------- ................ .............. ------------- ------------- .......... ......... .. ------- ---------- ---------------- ------------ . .............. ------------- --------- ----- . ------------ ----------- ------------ ------------ ----- ...u. ... .................... . ................... --------- - ---------------- ------------- -------------- --------- .... ... ... ---- -- ----- .. I .... ......... _ 70 -------------------- -------------------------- - ----------------- ----------- ---------- -- --------- ...... - --------- -------- Date ----- ---- Final Inspection by: ---- - -------- — --------------------- .................. 4 SAN JOAQUIN LOCAL HEALTH DISTRICT E.1 -'68 Rev. 5M . H. 9 q