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FOR OFFICE USE, <br /> I APPLICATION FOR SANITATION PERMIT 2s- <br /> ........I........................................ ...... 1, Permit N*6 .lComplets in Triplicate) .... <br /> ................q-........ ................. .. . <br />............................ .................. .......... This Permit ExpiresDate Issued- 1 Year From Data 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 Regulations: <br /> JOB ADDRESS/LOCATION� '150, .......... <br /> .... ................ ............ <br /> ....... ---- ... ... ................ <br /> '10-1 Phone <br /> .........CENSUS TRACT <br /> fl <br /> Owner's Name --- ..... --- ------ <br /> pp <br /> Addre ---------_---_ city ... <br /> Address .................................. <br /> Contractor's Name % <br /> .... ......... ......... ........License #A1 Phone 7...... <br /> Installation will serve: Residence Apartment House O'Commercial OTrailer.Coqrt 0 <br /> Motel 0 Others i......................... .................. <br /> Number of living units:...... ...._(.... Number of bedrooms ...3....Garbctge Grinder ...... ...... Lot'Site .... ............. <br /> Water Supply; Public System and name .......__............................................................................"k, <br /> .......................Private <br /> Character of sail to a depth of 3 feet: Sand 0 Silt 0 Clay 0 Peat 0 Sandy Loam,! Clay Loam <br /> .hard an 0 Adobe 0 Fill M6terlol ............ If yes,type ............................ <br /> (Plot plan, showing size of lot, location of system In relation to wells,,,wildirs <br /> gs,.etc.,must be placed on reverse side.) <br /> NEW INSTALLATION:, INo septic tank or seepage pit permitted if public sewer js available within 200 feet) <br /> PACKAGE TREATMENT SEPTIC TANK .........L Liquid Depth .... �.4............... <br /> Type e lze...... . ...... -2— <br /> Capacity a. Compartments <br /> ...... Material. N. ........... <br /> Distance to nearest- Well ................FoundatWr%,..>I_Q............. Prop. Line <br /> LEACHING LINE No. of Lines _,96............ 'Length of each llne......7 a Total Length ..............-7-1 C) <br /> ............. <br /> __�f�Type Filter Material ............. . <br /> '13, 'BOX .... . ....Depth Filter Material <br /> Distance-to nearest. Well .... .....t7- Foundation ..... .a., Property Line <br /> SEEPAGE PITDepth .......I............. Diameter ................ Number ------- ............ Rock Filled Yes ❑0 No ❑0 <br /> Water Table Depth ...... ..................r......................Rock Size ................................ <br /> Distance to nearest: Well ------ ::..........:..............Poundal... . .................... Prop. Line ......... <br /> 0\ " t <br /> REPAIR/ADDITION(Prev. Sanitation Permit#,7n.............!..­....................... Date ...�� <br /> .. <br /> f ........................... <br /> SepticTank (Specify Requirements! .............. ......................................... ............................................................. <br /> Disposal Field (Specify R equirements) C)� t <br /> ................................................................................ ........................ ....... <br /> .......... .............................r.........................................................:.................... ............................. ............ ------- <br /> I , _­yn I <br /> .................................... .......__1-------I................................. .............. .................................................. .............................. <br /> (Draw existing and req61rid addition on:reverse 'sidel <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 01sirict. Home owner or 111cen. <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work far which this permit is Issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ................. ............. .. .. .3. . ............ Owner <br /> .. .. . ........... ... . ..... .............................. ......................... <br /> J A <br /> By 5�--...I:! - ..,, -" \6 <br /> ............ �T <br /> ite ........... i <br /> IlAothe <br /> tr)th wner4-- <br /> O DE RYM NT U E ONLY <br /> APPLICATION ACCEPTED BY ... ...... ...... _3 <br /> ............................•.DATE ........ <br /> BUILDING PERMIT ISSUED _ .. . .. I .... .... . ............. ... ...... ..............................L..............DATE ............. ........................ <br /> ADDITIONALCOMMENTS . . .. ..... ... ...... .... .................... ...............00....................................................... . ....................... <br /> .. . . .................. <br /> --- --------- -- --- --- - ..... ................ <br /> ................ ........ <br /> .......... ..... .. <br /> ...... ....... ----------------- . ................. .......... ................................................................. .............. <br /> final Inspection by: ... ...............--1................­...... ............................................Date .....S... .....1,5-....... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 13 2 4 <br />