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F%M OF'rice u5el <br /> APPLICATION FOR SANITATION PERMIT <br /> ...................I..........Z..........�.............Z......I........................................... . <br /> m <br /> -rc> (1-7 Permit No . . .. . .e- ftw;W <br /> ' Dab Issued <br /> ......................................................... This Permit Expires I Year From Date Issued, (PIA,,J" <br /> Application n _kere6y inade to the Son Joaquin Local Health District for a permit. to 'construct and'Install the work herein <br /> d is ii caiflanis in6di 16'6M�116-iiie WIth-C60my Ovdin-6' - .d c -N 67549 and-existing. IRules and Regulo'tlonsl <br /> X0 <br /> JOS ADDRESS/LOCATION ............... P./...... ........... ..........k...........CENSUS TRACT <br /> .............................................. .......I........... .. .. <br /> Owner's Name ..........7-!�-�q..... ...............Phone <br /> Address .................._541 ....... City .... <br /> 4..- <br /> Fri .............................. .7 <br /> Contractor's Name ........ rLicense # <br /> Phan e <br /> Installation will serve, Residence Apartment House C3 Commercial OTraller Court 0 <br /> Motel0 Other................. .......................... <br /> Number of living units:... ...... Number of bedrooms <br /> ....Garbage Grinder .... ........Lot Slze ........... ............................... <br /> r. <br /> Water Supply, Public System and name ................................._­­----­---------........ ..................................Private <br /> Character of soil to a depth of 3 feet. Sand 0 Silt 0 Clay 0 peat 0 Scno�Loam C) Clay Loam' <br /> Hardpan 0 Adobe 0 Fill Material ............If yes,,type................ ........ <br /> Mot plaA, showing size of lot, location of system <br /> In relation to wells, buildings, etc, must be placed an reverse side.1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public jewer Is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK f ISize... . ............ Liquid Depth ...6Y <br /> Capacity Type ............... -------/No. Compartments -----_-------...... <br /> Distance to nearest: Well. .......................Foundation Zla� <br /> LEACHING LINE No. of Lines ...a.-.......... Length of each fine...... Total Lenith.". .!a ..... <br /> V Box Type Filter Material 1,hXa- U�.�,Npth Filter Matlerial <br /> _4.......... ....... <br /> ................. <br /> Distance to nearest: Well ...'a .........�ro_u6d_&Ibn C ........ Property Line 0 <br /> 41� <br /> SEEPAG <br /> E PIT Depth .................... Diameter ..........R_---:- lumb_ee .......... ........•........'Rock Filled Yes'o, No 0 <br /> Water Table Depth ---------_.—....... -------......Rock Size ............................i. .... <br /> y <br /> ...................... -jqundatr1001.`_'1 <br /> 'Mrstance to nearest: Well ........ <br /> p <br /> REPAIR/ADDITION(Prev. Sanitation Petmit .......................................... <br /> F� '\ t 11 - : <br /> Septic Tank ISpedfy Requirements) ......�t.-k ......j............ <br /> ......................................... .......iyi....... ........ I...... <br /> ............._fir <br /> Disposal Field (Specify Requirements!: ............... 1.1....... <br /> .......................---...^... .......___•_----- ---- - <br /> ........................I........................... .........I............................................. <br /> .............. .............................................................. ....... <br /> ............................ ..........................................................4--.....••.....I--.......... .......... ....................................... .............. ...... <br /> (Draw existing and required addition on-reverse side}J.1 <br /> I hereby certify that I have,prepared this application and that the work; wilt be done In atcardance iAth Son. Jpaquin <br /> County Ordinances, State LoWt, and Rules and Regulations of the—San jo <br /> a U cal.Health District. Horno.owner or licen- <br /> sed agents signature ce"Ifies the following: <br /> "I-cerfifi 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 bec,ome subj9d to Work 's Compensation laws of California." <br /> ynan <br /> Signed ...... .......................... ............... Owner <br /> . ............................... .........*.............................. --------------- litle ................................... ................................. <br /> of othef than <br /> FOR DEPARTMELT.,USI:,'ONLY <br /> APPLICATION ACCEPTED BY ....... ............................. DATE <br /> BUILDING PERMIT ISSUED ... .................DATE ................................ ............. <br /> ............. ....... <br /> =77 ..........�­................... ........ ....... <br /> ...... .......*...... ......... ....... .......... <br /> ADDITIONAL COMMENTS <br /> ................................................... .........................................................................I................................ <br /> ......................... <br /> ...............4............... ................................................ ....... .................. <br /> .......... ......... .............................. <br /> ....... .. .... .. ....................... ....... ....... ............................ ... <br /> final In'-s'p-e-c't*lo"n6'y':'... . ........... .. :" . <br /> ............ <br /> ...... ................................•-_...---•-•---......Date --- <br /> .......... <br /> EH 13 2h 1-60 Rev. 15H SAN JOAQUIN FOCAL HEALTH DISTRICT 8/7h 3M <br />