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FOR OF LICE <br /> Q-- FOR OFFICE USE: <br /> APPLICATION"r"GR SANITATION' PERMIT <br /> 4-93/ <br /> (Complete in Triplicate) Permit No..?.7--------- ------ <br /> Date Issued---6-7�,X-.7? <br /> This Permit-Expires I Year From dateissued <br /> Application is hereby madejo the,San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is mode jn'compliance with County Ordp' Qnce No. 549 and existing Rules and Regulations: <br /> JOB ADDR5SS/LOCATIO --- --- <br /> - ---------- ---------- <br /> ---- - -------CENSUS TRACT-•--------- ------- <br /> O%,�ner's Name------------- <br /> - ----- --------- - --------------- ----------. Phone------------- <br /> --- - ---- --- <br /> At ------------ <br /> Address----------- - --------------zip---------- ------------------- <br /> Coktracfor's <br /> Phone-,. <br /> 1- ------------License /- NOY/11/7 <br /> Installation,'will serve: 7esidence E] ApartmentHouseED Commercial ❑ Trailer Court EJ <br /> Motel-L] -,.Other-- ------L-2 ----­------------------- <br /> -N-umber of living un.its:--:.__-/------Number of bedrooms--.'-- Garbage Grinder-----------Lot Size_.` <br /> I : -------------- <br /> ,�Water Supply: Public System and'name------------I—— <br /> ii 11 .. .. . r� ---- --- -- - ------------ ------------------- -------------------- -----------------Private E] <br /> Character of soil to a depth of 3 ❑ <br /> f eet.e�, Sand.EJ,� <br /> 0.7 t, <br /> 'S Y ,❑ Peat ❑ Sandy Loam [] -Clay Loam <br /> Flapal <br /> M6166 Di ---------If yes, type--- ------------- <br /> Vill Material-, <br /> -------------- <br /> 3 <br /> C(Plot plan� , showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> 0 , - <br /> NEW INSTALLATION:' (No septic <br /> permitted <br /> ­ kseptic tank'or seepage pit permittid if public sewer is available within 200 feet,] <br /> PACKAGE' TREATMENT -[ ] -I - 4 1 1 1 <br /> 'SEPTIC TANK -1 Size-'-- 0-� <br /> - --- -----------Liquid Depth--- ----------- --------- <br /> ---­W-�Capaicity_ =Type <br /> --- ----M.b te'r,i'a I No. Compartments-------IPI--------------------001 <br /> ,to <br /> 4*X-77 -- --- <br /> nearest: Well------- - ---- -- --;-----------___Foundation_: Prop. Line-.'-�-777--------- <br /> LEACHING LINE 111 No. bf Lines_____ n <br /> Leng <br /> ---- -------------- ngt f each li e-/ <br /> --------------Total Length­/e7,�)----- <br /> ------------ <br /> �'D' Box_...____ __Type Filter Material:..-._ ------- epth Filter Material---/ <br /> F-- ------------------------------ <br /> Distance to nearest. Well.--------- 0 K-- ' I — <br /> .�.oundation­--49-0---------------Property Line- ---------- ---------- <br /> Number--- --- ---------------- <br /> Ro�kl`illecl YeA N <br /> SEEPAGE PIT A 3 0 Et <br /> T ­Ee th�--- ' '-F..�,a m t e'r <br /> '�Vater Ta-6le De-pth.-- <br /> ------ -- -------------- Rock Size-------- <br /> -------------- <br /> bistance:to nearest: W611------ - --------- A --------------- Prop. Line-----.Foundation-- <br /> (Prev. Sanitation Permit#-----:------------ --- -------- -------Date---------- <br /> ------------------------------- <br /> Septic Tank (Specify Requirements)-i---------------St-, r =----- ------------ ------ <br /> • <br /> --------------------------------------------------- ---------- ----------------- <br /> - <br /> Disposal Field (Specify Requirements) ---------- --- ----------------------------r-— ------------------------ <br /> ------------------- ------------ <br /> ----------- <br /> ---- -------------- ---------------------------------- ------------------- <br /> ----------------- <br /> ------------------------ <br /> ----- ---------- <br /> ---- ------------ -------- ------------------------ <br /> ------------------------ ---------------- ------------------------------------------!-------------------addition on reverse side <br /> (Draw existing,and required a <br /> I hereby-certify that I have prepared this application/and that the work we done in accordance with Son- Joaquin County <br /> Ordinances,: State Laws, <br /> and Rules .and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> sig <br /> nature certifies the%.-following- <br /> "I certify that in 'the-per­Forrnance­&'the �worl for' which this pei-it is issued, I shall not employ any person in such manner as <br /> to become subject t6 "Workman's Compensation laws lof Ca <br /> Sighed-7----- -------- -- -- ----- ------- -; <br /> ------ ----------Owner <br /> ---------- Title-- --------------------- <br /> - - ---------------- --- <br /> (if other than owner] - <br /> FOR -DEPARTMENT -USE ONLY <br /> APPLICATION ACCEPTED; BY <br /> -- ---------- ------------- -- ------------ ------------------ ---- <br /> ---------- ----- ---------.---------"------------DATE.----------------- <br /> --- DATE <br /> DIVISION OF LAND NIJMBER:-------- - .. . . ------------- <br /> ---- --------- I--------- --------- - - --------------- -----------7--------------------DATE------------------ <br /> ADDITIONAL COMMENTS. <br /> ..... ........... <br /> ------------ ------------------- --- ------------------------------------------------------------------ ---------------------- ----------- <br /> ----------------- <br /> ... ..... ........ --------------------- ------il----------------�w--------------------------------- --- ------------------- --- ------------- <br /> - ----------------------------------------- -- - - --- -- ---- <br /> ':-- - - ------------------- -------------------------------- ----------------- <br /> ---------------r---------- - --------------------------------------- <br /> ---------------------------------------------- ---- -------- - ----------- ------------i------------------------------------------------------------------------------ -- --------------------- <br /> Final Inspection by;--- ----- <br /> -------------- <br /> EH 13 24 <br /> N i UIN LOCAC, HEALTH DISTRICT F&S 21877 REV. 7/76 3M <br />