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- }' FOR OFFICE USE: <br /> EOR OFFIG� USE;1 �a APPLICATION FOR SANITATION PERMIT <br /> --- s Permit No. --7-7 -3VT <br /> ---------- <br /> (Complete in Triplicate) �, �t <br /> --------------------- ------------- ,! <br /> rr.si tDate�'I sued__7.'3-���-� <br /> ---------_------------------------ This Permit Expires 1 Year From Date Issued ([ n <br /> E <br /> Application is hereby made to 04Sa Joaquin Local Health District for a permit to construct andwinstal.1-the work herein described. <br /> This application is made in compliance-with.-,County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION_ Z_ �__f -! �.-- +' -'- <br /> CENSUS.TRACT------ •----- ---------' <br /> f - -- - -- ----- , <br /> Owner's Name. <br /> - <br /> f ....... <br /> Address-- ---- ------C -- --- ;, �..__ <br /> City ` iP <br /> Lac e4 T�_ ' _ Maneo / <br /> Contractor's Name-------- ens # -P <br /> • <br /> Installation will serve: Residence ❑ Apartineht,House Commercial Trailer Court <br /> y o th <br /> Mote[ er------ - - -- -- - ---------- + <br /> ! _e� Number-,of-bedrooms- Garba } <br /> q j I - ` d <br /> e Grinder.---- ----Lot Size- - -----(-�/---f--�+es!$ ---- ----- <br /> eNumber of living units:-_'__.._ :_____ - 9 - 1 ---�- � # <br /> )Nater Supply: Public System andame-------- --------------- = :. - t i <br /> 6- Priva e ❑ <br /> ---- , <br /> -Character of soil to a depth of 3 feet: Sand [] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ lay Laam ❑ :f <br /> ----- <br /> Hardpan ❑ Ad;be7K�F;I�I;Ma'te`rial__._.._ _If yes, type_______________ <br /># Plot Ian, showing size of lot, location of system In relation to wells, buildings,'etc, must be placed on reverse side.) <br /> r( P g <br /> IN• ' = --•-- <br /> r "NEW INSTALLATION: " ;(No':septic tank or seepage pit permitted`if public sewer is available within 200 feet,) <br /> f� r p <br /> PACKAGE TREATMENT [ ] . SEPTIC TANK ' Size----------------•�`�- -- -,-- -------.------=----- Liquid Depth 5i`f---- ------ <br /> ja.: <br /> CIF d ; # e. <br /> . - -- ate '-, <br /> NoCom. partm <br /> a _ _ Mlents <br /> -YtU _ _._ TYPCa cct . ?r <br /> �� ----------= ;Foundation. --------- Line--_-Distance to nearest: Wefl.= lfr <br /> LEACHING LINE No. of Lines_+:__.`'Z Length of each line____.__ g <br /> I # - -- r-----------.Total Length !__1&d----- --------'------ <br /> I `r ------------= <br /> D' Box------------Type-F_i]ter!1(4aterial __�_--__ ri----Depth Filter Material__..__.::.�8;-------------------=--------- <br /> Distance�'to nearest: Well--- ----------------i ---.Foundation_.------- Property Q-- - rty Line ------------------------ _ <br /> ., -. <br /> Er <br /> l ; <br /> SEEPAGE PIT [ ] Depth----------- ----Diameter---.-----------------Number -- �.___ y Rock F;Iled Yes El No <br /> Water TablelDepth---:---------------------------l : ---- - - Rock Size'------ x <br /> t Foundation. + .Pro Lane.-_ . <br /> -. ( Di•stance to nearest: Well______________.--------______-------____.- <br /> REPAIR/ADDITION Prev. Sanitation Permit#._ ------------------- -----=-- -=------- ---Date:.._________:_-_---------;------=-------- ) <br /> p (SpecifyRequirements) <br /> = <br /> Se tic Tank -------- =�-�--------- -==- = -------==----------- <br /> Disposal Field (Specify Requirements)------------- ---- t ----------------------------------- <br /> t' <br /> --- ------.- <br /> ' ------- ------------------------------ -'---- ----- . . - <br /> - --------- --------------------------- ------------------- ------------- ------------ <br /> -----------=-------------------- --------- <br /> (Draw existing and required�add;tic n on reverse side) F ' <br /> I hereby-certify that I have prepared 'this application and that the work will be done in accordance with Sart Joaquin Coum• <br /> Ordinances,: Stat Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agent <br /> signature certifies the folio ifig: t <br /> "I certify that in the performanof the work for which this permit,,is issued, I shall not employ any person in such manner as <br /> ce <br /> to become subject fo Workman's Compensation .laws of California:'.'.. <br /> w <br /> Signed-------------- -- ---------- ------- -------------- ------- -0 <br /> wrier <br /> ( BY--------------- ------ --- --- ---- �t - <br /> Titie.__ . ----------. .s ----------- <br /> 1:;4 other than owner) <br /> ' FOR DEPARTMENT USE ONLY, i <br /> t <br /> APPLICATION ACCEPTED BY A -------------------DATE. �����—----------------------- <br /> �' ----- <br /> DIVISION OF LAND NUMBER. ---------------------- ----- L DATE . - <br /> ._ <br /> ADDITIONALCOMMENTS.-------------- ---------------------=----- -------~ ,------=------------------------------------------------------------------------------------- -------------- <br /> t _ <br /> ------------------- - ------------------------ <br /> - -------•------------------------ti-- <br /> ^' ------ <br /> =---------------`a --------- 3 ------------ -------- <br /> -----s - --------------------------------- ----- <br /> : . <br /> 1 -- <br /> Final Inspection-by ii(( -�� -- - Dote ------`-__-- - ----------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />