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MM WrfL[ WiCt <br /> APPLICATION FOR SANITATION PERMIT , <br /> � ........... .. ................................... Permit <br /> IComplele In Triplitatel <br /> _ T Date Issued ::i.:. V=-�_� I. <br /> .-.....................I..........:................ This Permit Exptrys I Year From Dole Issued <br /> 1 � <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install .the work heroin <br /> described. This application is made I pliance wi . County Ordinance No. S49 and existing Rules brtd Regulations, J <br /> I <br /> ��A�'�'��.'. • •-••••_ ...............�y2 '�.............._......CEIVSl1S TRACT ............. . ......... <br /> Owner's Name .... .. .la . ..... .... ........ ...... ... .Phone ............. ...................... <br /> Address .... , ........... ..............................City ................. .. . `...... <br /> Contractor's Nam e .---...:__-� �,........ .................................:....:..license# ........................ Phone .............................. <br /> .... <br /> Installation will serves ResidenceApartmeM House Commercial QTrailer Court fl i <br /> Motel ❑Other................................. ._._. <br /> Q ! ; <br /> Number of living units{,_..__,! -"`._. 'Garbage Grinder Lot Stm .. ... :L � <br /> Numb of bedrooms ...... <br /> Water Supply: Public System and name ..........:................._...................—......._-_---»--------------------_--------- <br /> Character <br /> _-- -Character of soil to a depth of 3 feet: Sand'[] Silt[ Goy (3 Peat❑ Sandy Loam 0 day Loam <br /> f Hardpom Adobe Q Fill Materlat............If yes type........................... <br /> !,Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an revertq side.) � <br /> NEW INSTALLATIONt (No septletank or seepage pit permitted if public sewer is available within 200 feet,l f <br /> PACKAGE TREATMENT ( ] SEPTIC TANK I ] Size................................................ liquid Depth . ..--..._............_f <br /> ..... <br /> ....... Material...................... No. Compartments Capacity _--...._...Type <br /> ' Distance Yo nearest. Well .Foundation ... Prop. Line <br /> LEACHING UNE [ } No. of Lines <br /> ........ length of eadt line..............._....... .... Tota! length ............................ rn <br /> 'D' Box ............ Type Filter Materia{ ....................Depth Filter Material , <br /> - „ Distance to neorests Well Foundation ......... Property--Line ......-•.----`- <br /> SEEPAGE PIT ( } Depth Diameter Number -_ Roc Filled Yes Q 0fi, <br /> ... No <br /> Water Table Depth ...................... Rode Size ........................... <br /> Distance to nearest: Well . . ....... ...._.....__._....Foundation ... Prop. Line ..................... <br /> REPAWADDITION{Prev. Sanitation Permit# .�f " ................. Date ............................._j <br /> Septic Tank { l ............... . ......__•--- -=:��. . <br /> Specify Requirements -�...,�.... • - <br /> Disno I fl d (Sped Ra ulrements} ...... .. r . ...S 3�M .. .o "�'r.­ <br /> Di .4.. <br /> . ..__ .... ... ...................................................... <br /> ......:.._.._.._: _ t <br /> .... ................................................... <br /> (Draw existing and required addition on reverse side} ' s <br /> I hereby certify that I have prepared this application and that the work will be deae In •nwellance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local HeaHh District. Hoare owner Berri-Berri-Of z <br /> sed agents signature certifies the following: <br /> "I certify that In the performance of the work for which this permit Is Issued, I shall not emplay any person In such manner_ <br /> as to becom subject to Workman's Compens on`taws of,Ca)lifornia." <br /> S.gned X.. . ......... Owner <br /> • (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> ... DATE...... . ... . <br /> APPLICATION. ACCEPTED 8Y ..-_..... .. ,G�4':.............._...... .•._- ....:._.:...... ...... <br /> BUILDING PERMIT ISSUED - - _ - ��" � I <br /> DVE- <br /> ADDITIONAL COM <br /> MENT$ ....... _ �,p <br /> r .. .-..... .. ..- <br /> .Yom. .._. .... ...................... ---_--•- "1 ...- _. <br /> �.. <br /> .. .. ... ... ... ......_.......-...-_••_-_._-._.__-____--__................----------............ _...........................---------_----......... ...-- •--...__..-..--..... <br /> s: — i <br /> Final Inspection by: ..... .......... _...-..-.. Dat® - . .L -� ........ . <br /> E14 13 2h 1-68 Rev. q4 SAN JOAQUIN LOCAL HEALTH DISTRICT �7l, �! <br /> - f <br />