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FOR OFFICE USE: —APPI:' 'I'10N,FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) -- <br /> . �.. <br /> �--• Date Issued <br />.................................••--................. + This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the S Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made # compliance with County Ordinance No. 549,and existing Rules and Regulations: <br /> l ,� ? 1 �! Ute ..CENSUS TRACT <br /> JOB A_QDRESS/LOCATION�..1. --•- -�.... . ._-... ..�.. �.,(�.-...--�-. ....._-. ..,..-.- .......-........... <br /> -- ;... <br /> Owner's JName.,,.'.. t_,�(�!t....�.4 ._1--- 'a .y_.f _...._•• •..............:...............�....Phone f--- .................. <br /> . om s <br /> :�.:....._.:;.__._'.�:---��..:..:Y....:....Address .................... ........tCity <br /> Contractor's Name ..... _ .. .-.. , ...:.......................................�.....License #�����f�_..-_ Phone������..... <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court 0 z� <br /> R <br /> Motel ❑Other ......:.......... <br /> Number of living units:-..---/..... Number. bedroom Garbage Grinderlr .... Lot Size .� ..+ r-"----------•- <br /> r r I <br /> Water Supply: Public System and name��'s <br /> ` Prrvate.•- <br /> .....................Character of soil to a depth of 3 #eet:' I Sandilt❑ Clay ❑ Peat❑ Sandy Loam {] Clay.Loam ❑ L } <br /> Hardpan❑ Adobe Fill Material 40 .. If yes,type ........-- `--__-... <br /> (Plot plan, showingsize of lot, location of._system in.relation to wells,.�buitdings,_.etc, must be._placed.'on reverse side.) S <br /> NEW INSTALLATION: (No septic tank or sit.permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTICtANK1eeps T7 i Size.•._...-,��-�,-.r................. liquid Depth .... <br /> 'LJ - T ...... Gr`� Material--- ..!�� ��Na. CompartmentsLA <br /> ..�......::...... <br /> Capacity ..- ..------ - - Yp <br /> ) # <br /> stance tol€earest: Well .,.-... ....... .......Foundation ..C.. _l......... Prop. Line .=---..--•--- -...._. <br /> LEACHING LINE [ No, of Lines .... Length of ach line_` �_.,J ------ Total Length _. -, :...-.-- <br /> ---- <br /> 17' Box Type Filter Material G' ... [depth Filter Material <br /> Distance 't nes est: Well ...�/.✓�. � .._ Foundation ` ................ Property line ._._.......... .____ 0 <br /> r f T 4-� <br /> SEEPAGE PIT [ Depth ..-._-�:-_:.::.___ Diameter __- E.:�-__. Nuimberl.,,- ::.:,_..... Rock Filled Yes.210 Q <br /> l i <br /> Water Table'�Depth -- .. 'Rock Size • i ......_...__ . <br /> Distance to nearest: Well !......... ....... _ �.._........ Prop, Line <br /> .....#_.. Date --------------­--------- <br /> Septic <br /> } , <br /> REPAIR/ADDITION(Prev. Sanitation Permit�# .........-...-•------...-..•...-.. � •--•--.....•------------- <br /> Septic Tank (Specify Requirements)l---- --------------- ......_------_----- ....::::.................................... ...........................-.................. <br /> i C <br /> Disposal Field (Specify Requirements) ._.......................` <br /> + 3 _ .............. <br /> ------------------------ --------- <br /> 4 <br /> ' __•--...-..._--------------------.........T +___-.-._.....-..---,---------•-----•......... <br /> ..................--------- ------------------ ----••-•-- --•_---- -- .__--____• <br /> - - • •----------•---•---------- <br /> (Draw existing and required addition on reverse side) ' <br /> I hereby certify that I have prepared this application and that the work will be dbne in accordance with San Joaquin <br /> County Ordinances, State Laws, ands Rules and Regulations of the Son Joaquin local Health District. Home owMer or [icon- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of fhe work for which this permit is issued, I shall not employ any person in.such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed . <br /> Owner, -.-.._ . .-.... r <br /> B - G1 Title _s................ <br /> Y ----------------------------- ---- ..-- ......... Title <br /> other than nor) � � <br /> FOR DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED BY ..-- :.... DATE ._-... Z. - •_.._. <br /> BUILDING PERMIT ISSUED : ......... = --....•................... ........DATE .-•-=---•• ............................... I <br /> ADDITIONALCOMMENTS ••.... ...-....... _..........-•-••-••-•...................•••-••--................:........---._........-•-•-- <br /> • . .. --- --••••- <br /> ................... .............•--- --........ ..........i............... .............._................ <br /> 1 <br /> .. ... <br /> FinalInspection by: -... .. .....L..................•------------..........................................................Date _1_ ---— <br /> SAN.M1 JOAQU.IN LOCAL' HEALTH DISTRICT <br /> v+i w cern •re+A.++:w+�....—. nw. .'�k.1-...:iw-.:x-r�"aM',s' -. - _ . .•+-- <br /> 13 24 , .moo e... cu <br /> 7172 3 sK . <br />