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FOR OFf ICE USE, <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. ___7_1 <br /> -------------------------------------------- --------- <br /> i — (Complete in Triplicate) <br /> ----------I-----------------I--------- ---------- Issued <br /> 1 11 1_� <br /> Date <br /> n 1, 1� ------- This Permit Expires I Year From Date Issued <br /> --- ----------- ----------- <br /> it to construct and install the work herein <br /> eScin Joacluln'tocal Health District for a perm <br /> Application'is herglW macle�toj-� e S <br /> , ad- 'once with County Ordinance No. 549 and existing Rules and Regulationst. <br /> described. This application r, ade in compliance <br /> i CENSUS TRACT - --------- <br /> JOB ADDRESS/LOCATION ------ <br /> Phope <br /> Owner's Name ---- <br /> Address - -- ------------------------------------ <br /> -------- 44.0 M ­-------------------------- ------------------- <br /> ------------- <br /> ------------t_ city E- V------------------ ........... <br /> ------------- (0-0-0------ <br /> JLA( ------------------------ -------T�.License # ------- ---------------- Phone ------------------------­----- <br /> - --- -----------------Contractor s Name J�jl f <br /> Instal lation,wil I serve: Residence;gApartment House-E] Commercial'.[]Trailer Court ',E] <br /> MotelE] Other -------------------------------------------- <br /> ' ��l V&__1 Lot A�ize _ACRE0_&f__7----------- <br /> Number Number of bedrooms -------Gc�rlb�9-6 6rinder/_e______.1j_ __ - -I <br /> %I- __.. -Private <br /> Water Sup "Iy: Public System aJ name ---------------------------------------------------------------------------------------------------- <br /> pi it i- it '6m-0- <br /> Character of soli to th-q,.3 f6-et: - Scfnd'E3 Silt Clay E] Peat El bandy pdy Lo Y rod_M, ,K�v <br /> !It If yes,type ---------------------------- <br /> Hardpan 12�-!�Adobe'[­­I Fill Material <br /> q <br /> �j <br /> �o location of system in relation to wells, buildings, etc. must be placed on reverse side.), t , `0) <br /> (Plot plan, )showing; size of . <br /> I I i I able withi 200 feet,) <br /> NEW INSTALLATION: (No �septjc tank or seepage pit permitted if public sewer avail <br /> 01 <br /> ---- ------ Liquid .Depth ----- <br /> PACKAGE TREATMENT :SEPTIC TANK Size-------- <br /> o� Cd�76156rtmqnts 2.......... <br /> C,QType�?F(7WS�citerial__Ca(VCRF�TE_N <br /> Coppcity - ---------- - <br /> i f. Prop. Line --- ------- <br /> Distqjhce to nearest: Well --------15_0----- —----- -----Foundation --- <br /> Cy ­- < length r...... <br /> LEACHING LINE No. of LineX Z7,--------- Length of each line.____7 - ----------- Total vl] ... ........... <br /> -,Type Filter Material -------- <br /> D' Box t - --- ----Depth Filter,Material <br /> t, -Property Line ---Distance to - <br /> -W <br /> I e ----- il'ounclation <br /> 'Rock Filled No <br /> Number_--�------ ---------- Yes <br /> 7,..____e,_..Rock Size ------- <br /> -------- Diameter <br /> id <br /> SEEPAGE PIT Depth <br /> Water Table Depth ----,1"•7--- <br /> Distance to nearest: Well ---------,"--.Foundation Line _" ------------- <br /> ----------­--------- <br /> ----------­---i-------- <br /> REPAIR/ADDITION,(Prev. Sanitation Permit# -------------------------------------------- Date ----------- <br /> -------------------------------- <br /> Septic iTank,-(Specify-Requirements),;__zL:--z-.----_--.--- <br /> - ----- --- --------- -------- ------------ -------------------------------------- <br /> DisposEl Fi@d-(Sppcify Requirements) ------ --------I---- - ----------- ----- ------- <br /> I / LA XP <br /> A Al q��_ Al <br /> IV----- -------- - ------- ------- -4-----------. ....../- -------- <br /> --------------- -------? 7� <br /> --------------------I---- -- ------ --- ---------------- <br /> (Draw existing an r uire auumvL-0,,ivv reverse sided <br /> i <br /> I hereby lcertify ltliibtjj�hQ <br /> ' i prepared this application and that the work will be done inaccordance with Son Joaquin <br /> f "h Joaquin District. Home owner or licen- <br /> ances, State Laws, and Rules and Regmictions_S_ -Son.- aquin Local Health Distri <br /> County Cir 4in <br /> ri�s,sigjnature rtifi thefolio i g: e manner <br /> sed agent!j,jij ' 'es * <br /> "I certify t.in the erforman —work for which this permit is issued, I shall not employ any person in such <br /> I)! ___��Tn , a <br /> as to be "e.subje to Wo a Rom-perisation laws of California." <br /> Owner <br /> Signed --- ------------- --- - ---- ----- ------ ------------------------------ Owner <br /> -- -------- ------------ ------ ------------------------------------- iti. -- ------------------------------------------- <br /> (If otherAcin owner) <br /> FOR DEPARTMENT USE ONLY <br /> TE ------ <br /> R-01 DA <br /> APPLICATION ACCEPTED BY -----1-f�_ _1 --DATE ------- ------------ ----------------------- <br /> BUILDING PERMIT ISSUED -----/------ ------ ------- -- <br /> ---------------------------------------- -- <br /> _t�- --------------- <br /> ► ADDITIONAL COMMENTS -- -- ----------pir I - ----------------- <br /> _ .. ----------- <br /> ......... --- ----- -- --- ------- ------ ---------- <br /> -------------------------------- ---- ------ <br /> ---------------------------------------------------- <br /> - ---------------- --------- ---------- --- ---------- --- -------- ------- --------- ----------- <br /> --- ------------------------ --- -A;� _S7 i��26---------- <br /> ......... ------------- ------ - -------- ------------------------ ------ <br /> ----------------- <br /> ---------- <br /> ..�Date <br /> Fi <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 11-'613 Rev. 5M. <br />