|
FOR OFFICE USE,
<br /> APPLICATION FOR SANITATION PERMIT
<br /> ....... .........: (Complete in Trlpllcatel Permit No. .................... ;
<br /> .•-b.••-y�-"=y: ,��.4�•+�.�, .^•a.�«:..-. �m'�h4Por�`?•_x+w�• •:A�^i�• .�., _. ... - < ..c. �...:'...0=+�i.�'�x.:rYM-x ,ee,.r:^ Y. _ .. a...:r-K.,...ws.o.
<br /> a S _
<br /> g i 1
<br /> —4— . .,This Fermltfxpires >I Yoar:front Dowlsived --... ( .. tens } .z
<br /> : subd
<br /> Application is;hereby rhdde'to the$aii.Joaquin;Locdl Health' €strict:fora permit #o tonOru"c# aril inst61l flue work`heiein
<br /> describedThis application is mads incompliance with County'.Ordinarice No. 549 and:ex€Sting Rules,and.Regulations:
<br /> lOB,ADDRESS/LO.CAF ��' % :.. !. ._ .. I .. .. .........CENSUS 'TRACT ...
<br /> Owner's Name a - i -• • ' ` `. ..Phone
<br /> Address ' i , ... -r "� ° City -• ..............
<br /> ctor s Name - - - ... '�_ :.L€cense' Phone
<br /> § i s railer Court 0
<br /> E
<br /> `Motel(3Other
<br /> Installation will serve: 9 Residen A artnnent House Commercial
<br /> NumbeE of .living units:'_'=�j':= 'Numbe{{r`bf bedrobrris":` �.a. _Garbcige'Gil }' .. .. Lof.SFFize +'---....... .........
<br /> Water' Supply:'Public System and name. .. � .. . � ;. � `... j ..... _. � .. :-..Private
<br /> Character pf soil to a deptk of 3 feet. Sand❑ - lit[Q Clay Q -Peat:Q • Sandy Laamr•Q. Clay Loam Q
<br /> .HdMpan , Adobe fl.a_FillMaterial, .k. .. ; .!#Yes;type................... ...... s
<br /> s
<br /> (Plot plan, showing"size of'lot,•location of system in arelatiori oto"wells, buildings-, 'etc.' must'be placed on reverse' side.)
<br /> c L
<br /> NEW LL
<br /> INSTAATION• (No septic tank or seepage,,pit permitted if pubic sewer is availabie�with€n"2Q0 feet,)
<br /> �.
<br /> PACKAGE`TREATMENTs [.] -•.SEPTIC TANK 1 J <r :.~.,,."Size . .•- ----; : . . ,.Liquid Depth 4..
<br /> ---_-------_J-----Type .Material Compprtments' -
<br /> „w
<br /> Distance to nearest 1Ne11 __ :.-Foundation _ .._ . Prop.,Line
<br /> LEACHING 11NE �[ j No. of Lm s t. Length ch i. . Total Length __.
<br /> r
<br /> iF `f ea line .' } + ' iYl �
<br /> Box ...-- :- Type f0ter}Material § Depth!filter Material --- _ - --....... ---
<br /> ,_
<br /> ( D stance to nearest Well m Foundation I .'- . Property Llne -... , .._ _ �¢
<br /> SEEPAGE PIT J.
<br /> °r[ j ` 'Depth `�._. ... ,.-. i Diameer'r .. Numf er` _..__ .. ' Rock Filled' Yes ❑ No gQ
<br /> . i „Water Table Depth l.. _.. :, �.._P, :• , _ ` .:Rock Size i -
<br /> a
<br /> i � r
<br /> Distance'to nearest. Well ...foundation Prop line
<br /> s
<br /> R/A�►pITION:IP--rev. Sanitation:Permit'S4G--== --• �-•---� :---- i -••-�---•-=-�Ddte ...
<br /> REPAI ` t � ., ..} a •
<br /> Sep'tic.,Tpnk`(SpecifyRequicerrien#s) ? .......... ( i ...........1 t. :__.. .. ...? .._ ?..... ............
<br /> 1 .
<br /> ...
<br /> x pis osa1 k A ( y eq'
<br /> t I� '� t -
<br /> 1 Field (Specify 'Re" uirernents)_. --•� '--- . - Y
<br /> le.L.... .....
<br /> ._ q, � v.�•-r•g+.a, ,nr - ra,a.. ..�.qr,....:A•: •,.+�sat�:n a.+:. .� s:-� r
<br /> :--------•---- --- :--•-
<br /> _ 1
<br /> ^ {Draw existing and requfred cddition'on MVverse side)",1 : t
<br /> � g„rte.,'_.,.„ ,:,�.. : � ,'
<br /> 1-here6y certify”that I _Shave prepared Ahis application;and,th at',-the,work..will ,:lbe.done In(accordance with:San •loaquln
<br /> County Orclincincei, State laws, and Rules . nd'Regulailons of )rhe tan Joaquln theca! Health:Dlstrict Homo gwner,or llcen-
<br /> A �..,. a .,...a> :...:,. a S,.:, .,,y ., ,..»o,.<-:w a+w,: .....r..+,.R,,.. ry r.i .u..,t a• ...,:.-.gr .I..., i
<br /> sed agents sognatu"re certifies the following j i l 1 t I xs+ I
<br /> "I L certify that n.the.perforinance of the work for-which,thW permit is issued, l shall not.ernp!oy any person In such-manner
<br /> Y
<br /> a ned ecome subject to Workman's Compensation laws
<br /> Cal�farnia
<br /> as tab
<br /> 771`-17s ,
<br /> y Owner
<br /> $ x yrryfi-•.r-r.,a i ,.H � a. ''� - i � 9' •�{a SLA .e- Tnr -M •� f V
<br /> Q 9 i'- wq.r 'tie 4 vy r n�
<br /> V S a Y. T + ,
<br /> 'If.,other.than`ownerl,. �r�r.>r, r.aq�e vs!*a ^ax«n. sa..r'f..r.+a a+w.,,< .�. ri1—•- #r {-?: ^•�.,,., ;:�,o.. .#,.
<br /> " j- - , ,., FOR.DEOARTMENT.AAE ONL J..
<br /> ' r [ 1- - ------ ` - € D`AaE`5,..:r �.... .
<br /> A;PPlICATION,ACCEPTED, BY ..� �_ � ----_----•---.-,-• -.•..� -- - --
<br /> Bl1fLDfNG''PERAh1T ISSUED . ................... --- ------------ DATE ;_,.
<br /> 4-DDITIONA!_ COMMENTS ---- ----------------•---•-- ----------•--------.••• ------------------.-•----•--._.._..-...--•--...._...._.......:.. --•-._............_.....
<br /> ------------------_----------- ..-•------- ----------••---•--------•- .....------.... .. ............. . . --------- ...... , _..._...------ --..-....-•---------
<br /> --•-- ----.-- . - ---------- -----------•••------ -----
<br /> Final inspection by. .._............. - ----- ... .:_..--•----•--•.....................:. Date .! l` .. ._. .
<br /> f ' Eli 13 2L 1-68 Rev. 5M JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M
<br />
|