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FOR OFFICE USE I r <br /> / PPOCnT1011 OR SANITiATION PERMI' 7r� SO,/ <br /> 141111111, Fcrmit No. ........ <br /> (Complete in Triplicate) <br /> ` Date Issued 6 _�d_s....... <br /> V <br /> I <br /> This Permit Expires 1 Year From D•.te Issued <br /> Application is hereby mode to the Son Jooquin local Health District for a permit to construct and install the work herein <br /> lescribed. This application is mode in compliance with County Ordinance No. 549 and existi•tg Rule,. or•f Regulations: <br /> JOB ADDRESS/IOCATION .Jr !4 'f . �h. . ..`f. �.....�/...�cJ../ CEn . T. >CT ».. <br /> Ov/ner's Name ' • .. ......... ........ <br /> .. ... ......... ........................... ........................... _...�_... <br /> Addrass �..%.......� 10.y. .... .. ...City ....�ti'..t':r..,. • . <br /> Contractor's Name (. �+ L:�.. .t.�. t��- .1rL.rr•!�1. ...-'c. '._License ..� c�-' . ,... ?hone ............. . <br /> Instaliution will serve: Residence ❑Apartment House❑ Commercial Trailer Coit GY <br /> Motel C Other .... <br /> Number of 11 rig unix-, Number of bedrooms .......... .Garbage Grinder lot S se . . '� r' " ` '� ............ <br /> .. ...... ... ... .. .Private <br /> Water Supply: Public System nn ncme ....D......... Q.......... ❑ ❑ y ❑ Y ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt ClayPeat Sand loom Clay loom <br /> Hardpan Adobe ❑ Fill Material ... If yes,type . <br /> (Plot plan, showing size of lot, location of system in relation to ..wells, buildings, etc. most be placed on reveres tsbea <br /> NEW INSTAILATIOW (No septic tank or seepage pit permitted If public sower is ovallobl t within 200 feet.) <br /> PACKAGE TREATMENT ( 1 SEPTIC TAI..'' ' Size. . .................... liquid Depth ....... ... <br /> -.....�.. <br /> C01,06ty Type I . . . Material...... ...._. ...... No. Compartments ....... <br /> Distance to neo►estr Well .... . ..........I.......-Foursdaflan........ ......... . . Prop. line ..... r <br /> LEACHING LINE No. of Lines length of etxh line Total length .... .....»... ....__ 0 <br /> 'D' Box T Filter Material .. Depth Filter Material .. -.....� <br /> Distance a nearest Well ... . .. . .......... Foundat,on Property Line . . . . . _....-.... <br /> SEEPAGE PIT ! i Depth . Diameter ................ dumb*- Rock Fitted Yes ❑ NO QZ <br /> Water Table Depth ... ......... ..................................Rock Size ..........................»... <br /> Distance ►o nearest: Well ............. ................. ...Foundation .......... . ....... Prop. l{M .....-... ...._._.y <br /> REPAIR'ADDITION(Prov. Sanitation Permit tr . ...... Date ...................».-».........) <br /> Septic Tank (Specify Requuementsl ......... ». .................. . ..........I......... .. .Cf <br /> Disposal Field (Specify-Roquiremenisl .6o—C. <br /> -,T <br /> I/ !..i......... ......- .. . <br /> ,Draw existing and required oodition on reverse side) <br /> 1 hereby certify thet I have prepared this application and that the work will bo den* in attordentle with Segs JoKsslw <br /> County Orcinonces, State laws, and Rues and Regulations of tole Son Joaquin L*tol Health District. Hoose owtsor Of SCOW <br /> sed agents signature certifies the foliowiny: <br /> "I certify that in the performance of tlIe walk for which this permit is issued, I *hall net employ any Clers*^ {w eucls wserswM <br /> lee Io become sub;ec► to Workman's Compensation laws of CalifeMiW" <br /> S greed r . OwAer <br /> By _ . y '- it +r .;r\c Tills <br /> !if other thon owner! <br /> FOR DEPARTMENI US: ONLY <br /> APPIrCATiO'. ACCEPTED BY M DATE - <br /> SUILMNG r[RMIT ISSUED DATt <br /> ADDiTIOt•A. COMMENTS <br /> f.nai Ins{rl on by ,f... <br /> Det* -. 4 ...«r i ,/•/ <br /> SAN JOAQUIN LOCAL HEALTtt DISTRICT <br /> 7/72 3 A <br /> E H i - • 1 r? R r•v S M <br />