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FOR OFFICE USE: 'APPLICATION OFFICE USE: <br /> FOR SANITATION PERMIT <br /> —5 <br /> (Complete in Triplicate) SCA NMED --No-71------------- <br /> Vk Date Issued <br /> --------------------- --------- ------- This Permit Expires I Year from Date issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work here�' described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> p <br /> C_ <br /> JOB AbDRESS/LOCAt. <br /> TION ---------- <br /> -- ------------ ----------------- --------- - --------- ------ <br /> S U S ACT. <br /> Owner's Name'r�---- �nk <br /> ---------- <br /> C, A41V------------ <br /> Address------------ <br /> �rj <br /> #q�ractor's Name--;------------ - --------.--- ---------------------------Licen4' ------ - <br /> Instla onwillserve. Residence <br /> Apartment House E] Commercial E] Trailer pyrt. <br /> 0 --- <br /> : Other------------------ <br /> rt Mote! 0 <br /> --------------------- <br /> Nu,mberof living uf,�V------ ��&vmber of bedrooms ----Garbage 6 ----- -Lot Size ----- ----- <br /> rinder_____ ------------ <br /> Writer S6pPjIyPy10liC Sysit m o*;d me----------- ----------------------------- <br /> -- -------------------------------------------------------------------------------------------------Priyate <br /> Character of soil to cidepth of 3 feet: -�Sa A 'Silt El :Clay 0 P e;at E] Sandy Loam E] Clay Loam E] <br /> , <br /> Hardpan.0 Adobe Fill Material--.----------If yes,type----- <br /> - -----=------=------ ------- <br /> (Plot plan, showing size of lot, location ofsystemin relation tow wells,fls, buildings, etc. must be-placed on reverse sidej- <br /> NEW INSTALLATION: '(No- septic tank :or seepage e pit permitted if public sew' br is avail 161 with! 200 feeji,) <br /> paj a e n <br /> x <br /> PACKAGE TREATMENT; SEPTIC TANK Size-------- <br /> ----- _A-Z 4 __"Liquid Depth.:_ 7_ <br /> ------------ <br /> a <br /> --- -_--------Mpter -No. Compartments - ------------ <br /> Fou i 7" <br /> Distance to neareist:.Well..,-------- ndaton- Z 0-;.1--------Prop.! Line..X__1.'_.._._____,___.j- <br /> ------------ <br /> LE�CHING LINE P< No. of Lines-' --- Lendth� of e Z_CV------ ------T tal Len-gthL_L_;,__A?9_. <br /> --Lines_,--------- a-- h 0 --------------- <br /> D' Box----- _ Type Filter Material ------- __Depth Filter Material I,_k -------------------- --------- <br /> Distance' <br /> Distance to nearest: ovndati,,'6n-----A9-4 <br /> -----------Peoperty Lind. ---------- .......... <br /> -ffPAGE 0,#10�'� <br /> S __�u rn"ber-------------------------------- Ro& ill�d Yes 1Noj[] <br /> Water fd6(9- Depth'____` <br /> ----------Rock Size,460— -------------- <br /> TT ------------ ------- <br /> bistanc0b Nearest- <br /> � , V y- -- --------- <br /> ---- Founda t� <br /> n-___=_/Q___ <br /> .... <br /> ---- - ------- --- <br /> --- <br /> AIR/AO , Sonitatibn-Pernit#------ _._':Date <br /> --I <br /> I----------- -._'�Date---------------------------------- <br /> §e0tic Tank-15pecify-Reqvirementi)------ <br /> -;T- ---------- ------------------------------ -------------1�_-_______.___----_-_­ ------------------- <br /> 5 <br /> osal Field (Specify Rpq�jirements)--- <br /> --------- ------------------- <br /> -------------------------------------------------------------- ------------ <br /> Vp <br /> -------------------------- ----------------------- ------ ------------- ------------------- <br /> � _._L------------------- <br /> -------------------------- ------- <br /> ..................... _4---------------------------------- ------------------- <br /> 7--- -----_--_-------- <br /> 9. __j-- ------------ ------ ---------------------�_?, <br /> (Dcaw existing and required additionNon reverse side) <br /> uir d <br /> .,I horebi-cpTtify that I have prep hista�plica'H�;'�h)6Ad�lth6tthe work will be done in accorilaAce'4iih' '$yn Joaquin County <br /> lk"dh Jo4 uiA'L6tdI-'H6dI`tKDistriZt­Hbm n sed agents <br /> Ordinances Ahse, an. Regulations of t, 6 owner or liceh <br /> i'4 !Rture-certif h4 ihfollowing: , <br /> "I certify that in the performictrice of the work for Which this permit is issued, I shall'not employ:any -person in such man.ner�as <br /> to become subject to Workman's Compensation:..laws of Califor'nia." <br /> Signed------ <br /> ----- ---- -------- <br /> - ----- -- - & <br /> - Owner <br /> By_' Title <br /> - ----- - 4_ <br /> 6' '6r than:owner) -T- <br /> ----------------- --------- --- ------------- <br /> i/F01YDEPART I"N'T 11,5JONLY" <br /> APPLICATION ACCEPTED. BY -------------------------------------DATE---------- ------ <br /> DIVISION OF LAND NUMBER------------------------------ -- ----------------------------------------------------------DATES------- -------- --------­---------- <br /> ADbiTIONAL COMMENTS---------------------- <br /> ---------------------------------------------------------- --------------7----------------------------------------------------- <br /> ------------------------- ---------------------------- --------------------------------------------------- ......... <br /> C):na -------------------- ------- -- <br /> --------------------------------- ---------------------------------------------L----------------- ----------- <br /> ------------------------------------ --- ---------------------------------------------------------------------------------------------------------------------------- ------------------------ <br /> -tion by:- -------kv- <br /> Final Inspection ----------------------------------------------------------------------------------------------Date. = <br /> EH 13 24 v SAN JOAQUIN LOCAL HEALTH DISTRICT Fps 21677 REV.7/76 3M <br />