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4 <br /> Vl,,R OFFICE USE: APPLICATION FOR.SA'ITATION PERMIT <br /> .-.— .Permit <br /> ----- .. .... . AV <br /> (dinolete in"TriplHatell <br /> -- --------- 75�� <br /> ----------- <br /> i Ms Permit Expires I Year From Date issued Date issued <br /> ------------------------- -----------I---------------- <br /> Application is hereby made to the San Joaquin Local Health District for a per'mit to construct and install the work herein <br /> described. This application is made in com lia]nce with Cou Ordinance No. 549 and existing Rules and Regulations- <br /> NSUS TRACT -------------------- <br /> JOBJADDRESS/LOCATION <br /> ------------- ----- ------- ----- <br /> Own'er's Name -------- --------------_-------------------------------------- -------------------Phone------------------------------------- <br /> pi4A;n------------- city -------------------------­ ........ <br /> Address -------- e—,711 <br /> I. ---;X �__)_p <br /> Contractor's ----------License # /& . Q hon <br /> - ----------- --------------------- tt 4 <br /> Installation I will serve.. Residence fp� partment House-F1 Commercial ioTrailer Court:,fl <br /> Motel []Other ------- ----------- ------------ -------- <br /> Number of living units:-----__L Number of bedrooms-—--- -----Garba-ge Grinder <br /> I '_/�------Private <br /> Water Supply: Public System and name <br /> Character of soil to d depth of 3 feet: Sand'E] Silt 0 Cia,y ] Peat El rSbndy Loam 0 Clay Loam <br /> ❑ <br /> Hardpan E] Aclobe,�L-T- If yes,type ---------------------------- <br /> p <br /> --------:------------------ <br /> wells, buildings, etc. must V6 placed on rever— <br /> se tide.) <br /> (plot.-plan, showing size of lot, location of system inJrelation to <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is av liable within 200 feet,) <br /> av <br /> Liquid Depth <br /> PACKAGE TREATMENT SEPTIC Size----- -- Liquid <br /> ........ <br /> Capacity N_ Compartme <br /> IV yp 0 <br /> e --- Material <br /> ---------- <br /> We --------------Foundation -- ---- - ------------ .Prop. Line ------------- -------- <br /> • Distance to nearest:, ------ --- ------ - '^) Total Length ....... <br /> LEACHING LINE No. of Lines ... Length of each line- <br /> 'D' Box Type Filter Material _1_17,z11&_­kepthik Filter Material J-&----------------------------i--._•--lt - <br /> to ty Line <br /> '0 'rbvndatio ------------ Proper <br /> Distance to nearest, Well - - ---------------- - <br /> * Number Yes [g�'140 0 <br /> Diameter ---------------- Rock Filled <br /> SEEPAGE PIT Depth *D-- ---------- <br /> X ---- <br /> Water Table Depth ----- ---- I-------------- --------Rock Size -J----------- <br /> --------- Prop. Line ....... <br /> Distance to nearest, Well ------/ez9__D -----------Foundation <br /> L: <br /> REPAIR/ADDITION(Prev. Sanitation Permit _---------------------------1 7-------- Date ---------------------------------- <br /> --------------------I-------- <br /> Septic Tank (Specify Requirements) __,<�--- ------------------------------------------------------------------ --------------------------- <br /> ----------- ------ -------- <br /> Disposal Field (Spec'ify' Requirements) ------------------ --------------------------------------!-------------------------------------------- <br /> -------------------- -------------------------------------------------------i-------- <br /> ------------------------------------------------------------------- <br /> ---------- --------------------- i -A....... . <br /> ................. --------------------------------------------------------------- ------------------- ------ ----------------- <br /> -------- -------------------------------------------- (Draw existing and required addition •on rev6rse side) <br /> I hereby certify that I have prepared this application and that the work will, be done in accordance with Son Joaquin. <br /> Local Health District. Home owner or licen- 14 <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin <br /> sed agents signature certifies the following: <br /> 111 certify that in the performance=of_the work-for which.this_permitjs_issued,j,�hall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------- ---- ------- ------------ -------------------------- Owner <br /> Title -------- --------------------------------- <br /> By ----------------------------- ---------------------1_ Tit <br /> (If oth tih n owner) <br /> FOR DEPA27MENT USE ONLY <br /> --- ----- ------- <br /> DA <br /> 'APPLICATION ACCEPTED BY -- -- -- DATEDA ------- ------- <br /> ISSU <br /> DATE ---------------------------- <br /> --- ---------- ------- ---------- <br /> BUILbING PERMIT ISSUED ---- ---------------- ---------- ----------------------- <br /> --------------- <br /> NDDITIONAL COMMENTS ------------------------------------------------------------- <br /> ---------------------------------------------- <br /> -------------------------------------- <br /> ---------------------------------------------- ---------------------------------------------- ------------------ --- <br /> I ------- rte--------------- <br /> :�;-----0A <br /> -- ---- ----------------- ---- <br /> ----------- ---- ----- ------------ ------------rlo/ A-- ------- <br /> ------------------ <br /> .... ---------- -- ----------------------------------------------------Date-------------- ------- i------- <br /> "Final Ins Inspection by: ------------ <br /> SAN_JOA AU IN., LOCAL -HEALTH DISTRICT <br /> E. H. 9 1-'6a Rev. 5M. <br />