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FOR O FILE USEf PERMIT- -.APPLICATION FOR SANITATION PERMIT Permit No: ---- - ---- ;- (Complete in Triplicate) ----- - _� ----- , Date Issued - --1f !n' This Permit Expires 1 Year From Date issued - Application is hereby made to San Jo Health District for a permitto construct and install the work herein described. This application is made in comOwce•with County Ordinanee,No. 549 and 'existing Rut and Regulations: w a _____CENSUS TRACT• --------:------I----------- J "_/-. JOB ADDRESS/LOCATION ---- ! "" ; ' E +4t Q /r✓ ` Phone --------;" �l - " F_Owner's Name f Address # � Phone _L+cens Contractor's Name cial ❑Trailer Court ❑ Residence partment House°❑ Comer Installation will serve: Motel other ---------- " ' 1 �--- Lot Size - - -----�--- ------------•------------- � -___Garbage Grinder -- Number of living units-------. Number of I I `* Private �— Water Supply: Public System and name ------------------------- + ' Clay Loom 'D Silt Clay Peat❑'% ,Sandy,Loam ❑ a Character of soil to a depth of-3 feet. Sand'❑ ❑ a. + - d 'If; es, a ---------------------------- Hardpan ❑ Adobe` f ill Material _ /U---- Y type a + R buildings, etc. must be placed on reverse side.] (Plot plan, showingsize of lot, location of system in relation to wells, I � iC NEW INSTALLATION: (No septic tank or seepage pit perMi ed if public sewer is avail' within 200 feet,] "', Liquid Depth ---------------- --------- � SEPTIC TANK'[ ] � Size------- ----=-------------�- ----------- - .�, PACKAGE TREATMENT { ]• No 'Compartments ---------------------- Material -► I T e ---------- ----------- N' ."-------- ------ Type r¢ D stance to nearest: Well -,---------z'----------:--:-------Foundation ------- -------Prop. Line ----------------• LEACHING LINE [ ] 1\164f Lines Length of each line-_______--_"___----_"- -- -- Total L-ngth -------------- ------•-•---- + De Depth Filter Material -_"_�"- -----•---------------•------ 9' 'D' Box __--_------- Type Filter Material -------------------- p r Property-Line --------- -------------• C �...�.--'---- Foundation ------ ---------- ---- Distance to'nearest: Wel{ _- :--- j 1 Nurnbe�-%- _------------------Rock_F•i.[fed Yes ❑ Nod❑ a{ J SEEPAGE PIT [ ] �et?tht -------------------- Diameter ---= + .C ". . ---._Rock Size - Wateri Table Depth ------------ ----; t,. -Foundation -------------------- Prop:I Line ---•----------�... Distance to nearest: Well ------ •-------- - ' t , Date -----------------•----------------1 --------------- - REPAIR/ADDITION(Prev. Sanitation Permit# --------�--- ; �- -------" ---- ------------ ---------- .. r r Septic Tank (Specify Requirements) ------------- A / y/--,- Q��, p� r �( ^ •__. -------------- J l ..i/ Disposal Field (Specify Requirements) -------- - --- ---------------------- . -------� --------------------- ---------- --------------------------- (Draw existing and required addition-on reverse side) _ „__.,�. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ns of the San Joaquin Local Fleth District. Home owner or licen- County Ordinances, State Laws, and Rules and Regulatio sed agents signature certifies the following: ' for which thi "I certify that in the performance of the works permit is issued, t shall not en+ploy any person in such manner as to become subject to Workan's Compensation laws of California." ` Owner Signed ----------------------- ----- -- -------- --------------- ------ -------- ---- Title _.._ . _ ��- "'--- -------- (If oth owner] .� ! F94 DEPARTMENT USE ONLY tt = ---------------- -. DATE - ---^-A/-_-_ --------- APPLICATION ACCEPTED BY 1_._ --- - ----- -"-- -----"--"" - _ ' DATE '-BUILDING PERMIT ISSUED --- ------------------------------------ ------ � _ - - -----'-•G-''--- ADDITIONAL COMMENTS _. t�+ -' =--- --------------- - -------------- --- --------------------------------------- --- - } - -- -----T- - --�JO - ------------------------------------------------------ ------------------------ Final - -- - - ------- Date Final Inspection by: __._____ -- - -- ---- - --- N LOCAL HEALTH DISTRICT +- u 0 1_'AR Rev. 5M