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' FOR FIC, USE: <br /> `( � .-........f/r'aa... APPLICATION FOR SANITATION PERMIT S � <br /> r`t (Complete In Triplicate) Permit No��-.`°. .__... <br /> _. <br /> .......... This Permit t Year Date issued Dare Issued <br /> _ . f..�� <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This' pP ma incompliance cpe wi /unyrOrdinance <br /> inaNo. 544 andel existing Rules and Regulations: <br /> O@DRSS//LOCATiON -oQ ..`$ . NUS TRACT ......-............ <br /> ..._wn - l . _ ........ Phone <br /> ....._.. .. ......... - <br /> nL A <br /> Address ................ ..._city ...... ...... .... ... .. .... <br /> Contractor's Name---....... ----- .P.. ._ .......,.:_......License tit ,P.? -T.;.?�Phone ._._..... <br /> ,Installation will serve: Residence Ment Houser Commercial OTratlor Court Q <br /> Motel Q Other..... ... <br /> Number of living units:..... .__ Number of bedroom* .._... .....Garbage Grinder . .... Lot sizeG22 .�/.�..... <br /> Water Supply, Public System and name ..............................._.__........._.-------•--. _._..........................-............... <br /> Private l� <br /> Charocter of soll to a depth of 3 feetr Sand Q Silt Q Clay Peat Q Sandy Loam Q Gay Loam Q a`} <br /> Hardpan p Adobe Fl11 NloterlalW.P.if yes,type........................... <br /> {Plot plan, showing size of lot, location of system In relation to wells, buildings, etc° must be placed on reverse slde.lx <br /> INEW INSTALLATION: (No septic tank or seepage pit permitted if public se)ver is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK $ize,_.'T ��j10.P..,..._, <br /> Liquid Depth .A&............._. <br /> Copac' <br /> dY�tO�--•.-_--.. Type _. .. aterial[ No. Compartments .,�.......... <br /> ' D1 nce to nearest: Well .......s .... Foundation... o-2......... Pro Line ..a��_........ <br /> 77_��/ .�.. .... / P. <br /> LEACHING LINE [ No. of Un4s .y:4;2.- .o..f� Length of each line.._ ._�../ �1J <br /> ��jj '� ............... Total length �-••--.................. <br /> D° Box / .. Type Filter Material/Ga ....Depth Filter Material ..._/(j° ............................ <br /> �/ <br /> I <br /> n to nearest: Well ..{Y 9 D......... Foundation ... A...�......... Property Line - J..........° <br /> SEEPAGE PIT Depth ...v2. ,-4r--�___. Diameter Number ............. Rock Filled Yes g3--1q6 Q <br /> it <br /> Water Table Depth ......... Q,....r.......................Rook Size ..... <br /> Distance to nearest: Well _____/!5� ................Foundation Prop. Line -*S.—...__. <br /> ' REPAIR/ADDITION[Prov. Sanitation Permit dt........................................... Dote .................................. - <br /> Septic Tank (Specify Requirements) .................-------............................... - <br /> .................._.......-•- ---- <br /> _-....._................ <br /> Disposal Field (Specify Requirementsl ........................................ ........ ..................... . <br /> ---------------------------------------------------------..........-..-...-•----•--•----------------------..------------- ------.------.--•-------- ----------- <br /> •........ <br /> ........ <br /> .----------------------- <br /> ------------------ <br /> _ <br /> ----------_---------- ----.................................................-...........•------- .............---- <br /> lDraw existing and required addition on reverse side) <br /> 1 hereby certify that 1 haus prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Houilh:Disirid. Home owner or Beet. <br /> sed agents signature cortifles the following: <br /> "1 certify that In the performance of the 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 ---------- -- ------•-- fj -/y� Owner <br /> By ------------------- -�.�i 1/Uyr �/�.-----------...__..-- ---------•--.-. Title .... .... . . .lf.. ..... `... <br /> t ela r than owner] <br /> R DEPARTMENT USE ONLY <br /> APPLICATI N ACCEPTED By... ..... .. . ....... ----........----..._..-- ..................................... DATE .... -... /� <br /> BUILDING PERMIT ISSUED _.................. ... .:.:..............................:..:..DATE _' 1. ..............k.._.............. <br /> ADDITION <br /> L 0 <br /> - . ...... .... ...... ........................................................................._........_......_.............. - ._...... -- <br /> ....... � ... .. . :.. .. ........---.._ ----.......... ....................._......_......._.............................. -.............. _.... <br /> _........................ ...._............. ------------- <br /> . <br /> - ....._............. ....... <br /> --------- - <br /> ......................------- --------...-- ----- ---..... <br /> 1 - <br /> Final Inspection b , ........ . Date ..... ... � � <br /> ---------........_...._................................. .........._. .. .. <br /> Ell 13 2Lt 1-68 AN J AQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> i � <br />