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r%m Vrr-{,C VAC <br /> APPLICATION FOR SANITATION PERMIT <br /> ,1 <br /> ..................................................... (Complete in Triplicate) Permit No. . .7..5.:........ <br /> ........... .... ............ ............... ... This Permit Expires 1 Year From Date issued Date issued 1.:. �..7� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work !renin <br /> described. This application Is made In compliance with County Q01nonce No. 549 and a Isting Rules and Requlatlonso <br /> .. a` �'�/L"G11�. N �rl-Fl+ NSUS TRACT .......................... <br /> JOB ADDRESSOCATION I <br /> n <br /> Owner's Name .....;.. ,1.11111.+ r. _ /.. �L'L. <br /> ��pp E'f''Ci�i .......��.. ..... ..Phone <br /> Address ........................ .!: `. g C._. . ...... .............:------.......I City ...veto..... ...f^E��q�................................. a <br /> Contractor's Name .................. tAP7,�A!', , . .....................License# ........................ Plume Akio................_... <br /> Installation will serves Residence EyApartmer#House Commercial❑Trailer Court C <br /> ' Motel❑Other - . <br /> Number of living units:............ Number of bedrooms ......Garbage Grinder ............ Lot Size ....1.� f.- '�.j.: .S.............. <br /> Water Supply: Public System and name ..................................._......._............_..................................................PrIVcft X <br /> Character of soil too depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat[❑ Sandy Loam ❑ day Loam W <br /> Hardpan Adobe C] Fill Material ............ If yes,type.......................... <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEIN INSTALLATIONe (No septic tank 'or <br /> ee ge pit permitted If pubUc sewer is available within 300 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{rSize. ........................................ ' Liquid Depth ...... ...... <br /> Capacity . ...... Typol.9 <br /> L-. Material.Sn oW.t e._....... No. Compartments ..: ..._. <br /> Distance to nearest: Wall ..... •...............Foundation -L...-... Prop. Line ................. ..a" <br /> LEACHING LINE No. of Lines ....�..�........... Length o each line.. .: Total Length ..... ........0 <br /> 'D' Box ......1... Type Filter Materi . 1�apth Filter M terial .....---.. �1. ��... ...... 1 ' <br /> Distance to negro h Well ..... ..`.. Foundation ...... Property Line ...::.. ............... <br /> SEEPAGE PIT , Depth - 4R 2 .. Diameter .. ....... Number .........-0�.............. Rock Filled Yes No ❑40 , <br /> Water Table 6olith ............. . .. . .. ..................Rock Sire ........-- . . <br /> Distance to nearest: Well .....� ...................Foundation -/LCA..... Prop. Line ...t .. <br /> REPAiR/ADDITION)Prov. Sanitation Permit# ............................................ Date .................................. <br /> SepticTank (Specify Requirements} ......................................... ...........•--................................................. ..........._.............. <br /> DisposalField (Specify Requirements) ................................................................._..............---......._.._...............I................._. <br /> .. . ........I...............................................................I--.......I........................................................................................................... <br /> ................ . ..............................•-•---• ................................................. <br /> (Draw existing and required addition an reverse sidel ...._.......---................---......... <br /> '9 <br /> 1 hereby certify that I have prepared this application and that the work will be done in 4caw4ince with San �eegtitie"-�" <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne 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 /> os to become sub(- to Workma ' Compensattoh I of California." <br /> Signed ...... .............. Owner <br /> By ...............................•-............................._...... ......._. jitle <br /> (If other than owner) <br /> MI DEPARTMENT USE ONLY ;; <br /> APPLICATION ACCEPTED BY .............. ... ..... ....-........._..................................................... DATE ...... ... .� .....:�: <br /> r <br /> BUILDING PERMIT ISSUED ..........I..................... ..........DATE-.:......................................... <br /> ADDITIONALCOMMENTS ....... .........:........................................................... .. .. ..............P...........-..........--- ...................--......... <br /> ... .. ..... ................................•- .........-..........I........... .................................... ...........................�......-----..... .. <br /> Final Inspection by: _ r1 '.z�': :r rq. �.. ...,.. Date .'r? �.p. <br /> ........................................ ........`. . <br /> EH 13 2 1"60 Rev. 51� SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H <br />