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USE: <br /> F 1' APPLICATION FOR SANITATION PERMIT <br /> `-- _ (Complete-in Triplicate)_.._.__. Permit No. _= ��� <br /> i Date Issued _,5P ,O <br /> tThis.P.ermit.Expires I YAV4om�Date4sued <br /> Application is hereby made to the San JoAquin Local Health Districi oma permit to,co7�struct an = install the work herein <br /> described. This application is ma�-irficorn piian with County &d AaWnce�No. 549 and,existing Rules and Regulations: <br /> 10B ADDRESS/LOCATIa <br /> O _. �-_��-�_ ' <br /> I � �1 -- �: ���-� '--- -----•-�---- ----- ----- �---------. _----�-_CENSUS TRACT -- <br /> Owner's Name 'u'l,l -- hone7 _1_ ^¢ice <br /> _._ _ .- <br /> �+ 1 <br /> Address - ►�? i.aJ =� C------------- Cit I <br /> Y --- -- ----- - ---- - ----------------•-- <br /> Contractor's Name . T� '9 <br /> --------- — cense-#�4 ? - hone <br /> 7 <br /> Installation will serve: Residence ❑Apartment Hoase,❑ Commercial :❑Trailer Cou <br /> Motel ❑Other ______ �____ "-AbW I 4 <br /> Number of living units_____________ Number�`ofredr., oms -________._ Garbage Grinder ____ X !w <br /> estrot Size c1 ---- ------------- <br /> Tc <br /> . <br /> Water Supply: Public System and name __-____ __' ____ 1 <br /> pp Y Y ' Private ❑ <br /> s <br /> Character of soil to a depth of 3 feet: Sand'❑' Silt❑ Cly ❑ Peat❑ Sandoa� E] Clay, _Lyoam [3, <br /> Hardpan ❑ Adobe,[ Fill Mciterial _______ __ If ye tyl5e ------- - <br /> (Plot plan, showing size of lot, location of system in relation to wells,,�u&Nlgs, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit perrri'itledfpulIic�sewe is availablie within1200'feet,) <br /> 1 J <br /> PACKAGE TREATMENT �' Liquid;De'ph <br /> [ ] SEPTICt>4Iv.F[ ] Size____ <br /> - <br /> Capacity ----------- - Ype - Material - � No Compa. meets - <br /> t T .� „moi 4%. <br /> ------------------ <br /> Distance i nearest: Well -------------- ' y :Foundafion _._____ _____--_____Prop. Line ________-___- <br /> LEACHING LINT; [ ] No. of Lines ------------------------ � ^ ± t---------...... <br /> - -- 'Total Len th <br /> ---------- Length of each lih � ^ _`�-� <br /> 'D' Box ------------ Type Filter Material _____be th Frl e- Mat Hal - j <br /> SEEPAGE PIT [ ] stth ce t6 nearest: Well ------------------------ Foundation ---- --------- Propirty Line ---:-----.------- <br /> De -•-•-•- <br /> Depth i Diameter ---------------- Number ------------- -------------- 4kock;frlled Yes ❑ No .I] <br /> • Water Table Depth -------------------- ----------------- <br /> ock_Sizet. <br /> Distance tol �_,.I nearest: Well ------- ------------------------- -----Foundation ____ --- ----•_--- Prop. Line ----__--------------- k <br /> ttEPAtitfADDlTtON(Prev. Sanitation Permit# --------------- D t --------------_-- <br /> Septic Tank (Specify Requirements) -------_-----------_______ -- <br /> __ __ _ _ _ __---______cln e__._____F _ ___ _ _ _ <br /> Disposal Field S ecif Requirements) --------- -- ---__ <br /> --- --- ---- _._ -sss <br /> - --------------- - <br /> (Draw existing and <br /> required addition on reverse side} <br /> 1 herebycertify that I have re <br /> fy p pared 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 Health District. Home owner or licen- <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 employ any person in such manner <br /> as to become subject to WorkmanY+Compensation laws of California." <br /> Signed I !-- -.......°Owner <br /> . <br /> BY ------ - -------------------- Title -- ---------------- -- - f <br /> of er th weer} � � . <br /> O PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ..-_-- - DATE _- <br /> ------------------------------------------------- <br /> ILDING PERMIT ISSUED _-._______' - ------ <br /> ------------ ' ------------- <br /> ADDITIONAL COMMENT <br /> `Ak ------------ <br /> r <br /> - ---------------------------------- <br /> -- -- ------------------ t� F -'-�' -- - ----------------------------------------------------- <br /> ------- - - ------ ------ -- - ------------------------------------------------------ ------------------------------------------------------------------Ins action b ----- -------------=---- <br /> pY __. -- -- - - --------- -------------------------------------------------------------------.Date <br /> AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 - 1-'b8 Rev. 5M <br />