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-jF fOR OFFICE USE: o IWA t4 -7b USE: <br /> APPLICATION FOR SANITATION PERM T <br /> ...................... . ... ........ <br /> IE �It (Complete in Triplicate) Permit <br /> ............... <br /> ............................. ................. This Permit Expires I Year From Date Issued Date Issued <br /> Application is e�t4y made-to-the An-doaquin Local Health District for a permit to construct and install 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 ...... ------------ -.,..-.--,CENSUS TRACT.........+D-- -------- <br /> o <br /> Owner's Name.�.--- 4- i��L <br /> r- <br /> VIP <br /> --Address.-- <br /> ............................­.._.._...................................C <br /> Contractor's Ncime__0-W-Awt-ft- <br /> .........W------- ......... Li <br /> ...? ............................. <br /> Installation will serve: Resiclen-A-b5 Wxp-po��vtmenTHo_UZ <br /> ii[]"—Cornmercial 0. Trailer Court ❑ <br /> Motel �7, Other... <br /> Number of living onits....4 Number.8t-bddr�1oms.*..,7____G .................... <br /> �rbage Grinder....._......Lot.Lot.Size...... <br /> Wc�ter_tup "'Pul3lic-S ern and name.. A....... <br /> ............. ------- Private E] <br /> W3, <br /> V� <br /> Character of,soil'to-d-61f'pth of 3,feet; Silt[2 4;:,C 1 c,5 d", Peat D Sandy Loam 'Clay Loom ED <br /> ti <br /> "-Adobe-UL - ill-Materia <br /> I If yes <br /> type------_------­- ...... <br /> =,j <br /> 4-o -sy-Xien."];�,-*fn <br /> (Plot Plan, sh6�vjng.tiz.Z af-Idt-l-ocoti.0A. f- `S.. .... i-_Iotlon to wells, buildings,'etc.!must be placed on reverse side.) <br /> ��',)t �eiAitea if public voila6l- ;�',ithi <br /> NEW INSTALLATION:L".(No:septl-ilc tank e n 200 feet,} <br /> SEPTIC TANK, . --------- ----"Liquid-t--tiquia Dept --_--------_- V� <br /> PACKAGE TREATMENT <br /> V. <br /> Copocity.f. pe z7-IN aerial_4:iAerc- aw ments.....z., <br /> :_!.No.-Corn rt ----------------- --- <br /> Distance to ne are • WJ.-bt!: ------------_ Fou'ndation..'-,/.tl_.*-..,*Oe..Prop. Lint_ ......_­,74........ <br /> 4. <br /> LEACHING LINE; �4o..'of Lines.._. ..ALe6gthpf_eac'h 1100 _�;� <br /> . ota I.Length....... ...... <br /> OR OF, D' Box...._....,-..Tyie <br /> Filter weT <br /> Z91-A <br /> 74nearest:We0t N,R09%, /_A_../.Piaperty L e' <br /> SEEPAGE PIT Depth..--:........... ........... '-Yes No[] <br /> ------ -------------- Rock Filled-: <br /> • <br /> Water Table Depth. .............. _-Rock-.Size........................ ....... <br /> ---------- <br /> Di0once,t6 nd&est:'Well.w----------------- -----_----.-'.-..'...'--Foundation.......................:..Proo. Line----_____._....._ <br /> REPAIR/ADDITION-(Prev. Sanitation Permit#_________________.::................ ---....:.Date- -W............. ........ <br /> t <br /> Septic-Tank (Specify--Req u i rementi).....:......:......:.........••..._------=--..-=- ........ -------_------- .......... f,-----_ ••-------- --- <br /> Disposal Field.(Specify Requirements) xio: <br /> 47 <br /> ......................: ............. .............................. ............. ----------------------------------- .......... 7 ......... <br /> ---­----------------- ------- .......................... .......................... ....... . ... ............ <br /> ..................... ..... <br /> ...........................W--------- <br /> it se el <br /> '(Draw existing and required addition on rever- 'std'd' 17- <br /> I hereby certify that I -have-prepared this application and that the work will-be done-in 4ccordance with San Joaquin County <br /> Ordinances, State Laws, and Ruiles-and Regulations of"the" Son Joaquin Local Health Dlitrict. Home'owner or licensed-agents <br /> signature certifies the following: <br /> "I certify that in the performance of the Work for which this pernift Is.lssued,.I shall not employ any person i.n such manner as <br /> to become subject to rkman'LVComp�nsa�on laws of Calif orpia"a—', <br /> Signed... <br /> .................. <br /> ..... ...... <br /> ....... .... <br /> ByJ......= ....I--------..................................... .... ----------------- .............r ------r­---------­ <br /> "(If other*than owner) <br /> j6k DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__-_ ------ ..... ... ..........DATE.:- <br /> ................ ---------­---- - ............... <br /> DIVISIONOF LAND NUMBER...w............•--------- -----------------7-------- ............ ......................... DATE............... ....... ......... <br /> -- ----------- ------------- <br /> ADDITIONALCOMMENTS...............................*--------------------W--------- .....................­;--------------------------------------------------------------------------------- <br /> • <br /> -------_----------------------W...................... .................................. ----------------- .........::...... .......W.--w-:........;.........................­........ <br /> -----------------­----- ....................... ......... <br /> ..................:................... - - ------------- --------------------------------------- <br /> ---•--....-•••--­-------------- . . .... .......... . ... .........------------------------------------------------------------------- <br /> - <br /> Fincil-Ins'pection by:....... ...... ..... <br /> �-­... ..:.... ...........................................................Da e-7 <br /> E" '3 24 SA JOAQUIN LOCAL HEALTH DISTRICT F&S 7176 3M <br />