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n , <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> x APPLICATION FOR SANITATION PERMIT <br /> Permit No... �'P y <br /> (Complete in Triplicate) 7.. ._,. .. <br /> ? ........................... ------------ Date Issued...C• 21 79 <br /> This Permit Expires T Year From Date Issued `r <br /> " `. Application is hereby made to the Son Joaquin Local Health district for a permit to constrbct and install the work hereirn'described. <br /> This application is mode in compliance with County Ordinance No.549 and existing Rules and Regulations:: <br /> JOB ADDRESS/LOCAT! .- --:/-Z��_.._....t :..p< a / !,- __CENSUS TRACT. s <br /> f 3 CLu ¢�v ./1tcPhone c� y�iy� <br /> Owner's Name....... <br /> :. ss......._.. <br /> (v. --------- <br /> ZAddreCiy rP� __ C .�Contractor's Name:..._.: Phone -c ---------_---- <br /> ------- <br /> License <br /> x y '; Installotion will-serve Residence© . Apartment Houma 0 Commercial[] Trader Court ❑ M ;, <br /> Motel ❑ Other.... .:.............. , <br /> Number of living units.-'. /.:._:.__Number of bedrooms.. ......Garbage Grinder.......... Lot Size <br /> .; Water Supply. Public System and none-- ............. ... ...:.......... 1?rrvate [� <br /> Cha oder of so,l to a depth of 3 feer• Sand❑ Silt❑ Gay❑ - Peat❑ Sandy Loam E]-;'--Cloy Loam <br /> Hardpan❑. Adobe 0 Fill Material.. .........I#yes,type------- ..._ .. _ <br /> s <br /> (Plot plan; showing size of lot, location of system in relation to wells,buildings;etc.must be placed on reverse side), <br /> ,1NEW:INSTALLATION: ,(No'septic.tank,or seepage pit permitted if public sewer is available within 200 feet} z. <br /> it �•I-�.�►. _e... . . . ..:Size.MaterialSCC��_t..._`�.NNo. Com' artment <br /> " PACKAGE TREATMENT ( ] SEPTIC TANK Lr uid.Depth S+? 3 C <br /> 3 t Capoc y... yp Q P s--t.­.Z - <br /> vet Distance to nearest:.Well.:...._ID.......:....:.:.._.._..._.Foundation..:.:.f Prop. Line <br /> s , ' <br /> ` LEACHING LINE. [�No: of Lines............... :....Length,o�f�each line...:.. C...__. ......Total Length �� _ <br /> Boxl .r-Type Filter Material.,/ ���t!Depth Filter Material................ <br /> l; Distance to nearest:Well,.-_j.3p-------_.... Foundation ....�.� ....... _..Property Line-i <br /> S �� Number_.._....... Rock Filled Yes NaL <br /> y' SEEPAGE PIT Depth.o�........_.Diameter.�O..r.......... "_"" / / (� ❑�Z' <br /> LWater Table Depth....... ..c...._ .. Rock Size_ , <br /> ` Distance to nearest:Well... ...........Foundation Prep tLme I� r <br /> r . REPAIR/ADDITION(Prev.Sanitot,on Permit#..:...................----------------:............Date....... <br /> t Septic Tank (Specify Requirements(__ ........ .. . . . ......... .................. :_..._.._........__ �. - <br /> Disposal Field (Spec.fy Requirements)-........... ..... . ...... ......._._.._................_.._..._..------ . <br /> ..... ......... .......... .. .,.. ...._:.._.-. ... ..... ._..__...:..._......-----........... ......._.,...._._......._.._ �i'" »,� <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 done in accordance with San Joaquie,_County <br /> c Qrdihances, State Laws,'and Rules and Regulations of the San Joaquin Local.Health District. Moms owner or licensed agents <br /> r <br /> sigriatvre certifies 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 as <br /> to become subject to Work an's Compensation laws of California.' { <br /> Signed_...-.. .. ._... ..., ...... <br /> :...._.... C>vvner <br /> nn <br /> c- �..- <br /> ui <br /> (if othzr than owner] K <br /> FOR DEPARTMENT USE ONLY 7rf <br /> a <br /> APPLICATION ACCEPTED BY d Z��/ T... -. <br /> DIVISION OF.LAND NUMBER ..... ................ /.. :... _....... . <br /> DATE ' <br /> DATE <br /> ADDITIONAL COMME14TS -•- -------- .................-- ... <br /> ....................... <br /> . <br /> ................. . ...... ... ... .... ....... .........-...--. ..._• •---�. ..._...__.__.... .... <br /> ... _. <br /> Final lnspecrion by:.. - ---.7`� :.. <br /> 1 fm U 21 SAN JOAQUIN LOCAL HEALTH DISTRICT, r3s sign eEv.rna aM <br /> Af <br />