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x , <br /> FOR bFFICE FUSE: I FOR OFFICE USE: <br /> I �iAPPLICATION FOR 5ANITATION PERMIT. � g <br /> -- ..............:.�.-.. .. -�. Permit No. ./&)7- . ..• <br /> (Complete in Triplicate) R <br /> Date lssued.j.-/--.� <br /> f <br /> .................................----------........I�_--- - This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaq lin Local Health District for a permit to construct and,install the work herein described. <br /> This application,is.modeAn compliance with,County.Ord inonce <br /> No. 549 an�,d.eexist.ing Rules and Regulations: <br /> ,., <br /> S/LOCAT N _ ..11 Q .�0.-. .,.. 4. --- - 1 CENSUS TRACT <br /> JOB ADORES i- II <br /> �9 <br /> Owner's Naine.. _.-... _" - `' :.. R-.Phone.-- -. -d-_6- �,7......- <br /> Address-... Q.,. ..�I- A. .CWS nh� ----------.- Zip <br /> .. <br /> City_*%,- <br /> Contractor's Name...f.. i... .. ..� ..-.......- License #� ,5Y3.__. .Phone.%4-7 07-------- <br /> Installation will :serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Mlotel ❑ Other -. ----- ---- --­ ----- - <br /> Number of living units:---'-. -- •';'-Number of.bedrooms -: --...Garbage Grinder-.---.-._---Lot Size-----_-:._--.-...._ ,..................... <br /> .I -- ` ---Private <br /> Water Supply: Public System and name - --------------------------------•--------------••--------------.--- - <br /> t Chaff atter of soil to a depth.of 3l,feet:_r Sandll❑ Silt ❑ Clay ❑ ' Peat ❑ Sandy Loom ❑ Clay Loam[ <br /> — Hardpan L] .• Adob�e� Fill-Material - ...: ....If yes, type............::.:.'_............... <br /> I <br /> I (P.lot plan, showing size.of lot,location of system in relation to wells, buildings,-etc. must be,placed on reverse side.) <br /> NEW INSTALLATION: <br /> IN se tic tank or I1seepage pit permitted if public'sewer is,available within 200 feet,) ,r <br /> PACKAGE TREATMENT u,. II r t ` <br /> ( j SI�IPTIC TAMC '�Q Size -- - ?.-.... ----K� Liquid Depth.----0. _ ..-.--_--- <br /> /B <br /> Capocily-6 hh Type No. Compartments ..-.-.. <br /> II r.......Material-.. .-. _ -.: ' r <br /> Distan l�e to nearest: Well-...--.... d._ .- ---- . _ _-------Foundation:----10 ....Prop. Line--.. _+_..------- <br /> - <br /> LEACHING LINE No. ofiCLine s -.-... t..............Length of each fine"- ,9,0-._ -:--- -,Total length :..�70._.._...---...----.-__-- <br /> . . <br /> it .II A <br /> t 'D' Bo I�.-_-hype Filter Material__,�t�......Depth Filter Material------- ---s1----------- ------------------- <br /> ° Distance to nearest: Well_------�Q.._._.t...Foundation.....�Q.__'�---.._-.--. Pro ert Line.--- ---__--. <br /> SEEPAGE PIT [ ] Depth._llr...._.-.".--.....D.iarrieter.,.--------.--�.,::,.Number------------------------------- Rock Filled Yes ❑ N <br /> r-- <br /> Water Table Dep#h _ . <br /> - ------ ----------=----Rock Size--.-- ....-.-- ---`•------------•---•-- <br /> - I� <br /> Distance to nearest: Well-------------------------------------------Foundation-- _--------...:-....._.Prop. Line-----.------------..---- <br /> REPAIR/ADDITION (Prev. Sanitcitlon Permit#I---------•------•................. ...............Date----------.----.-----...-..-.- ............... <br /> Septic Tank (Specify Requirements) ` A - :. . <br /> - _ -- <br /> ! ilI <br /> Disposal Field (Specify Re uirements). = ------------ <br /> - -------- <br /> - <br /> ' (Draw existing and requi�ecf'acldition'on reverse side) <br /> re <br /> PP ; <br /> II. <br /> I hereby certify that I have l�a' Pp <br /> red this application and that the work will`"be done-in--accordance with Son Joaquin County <br /> Ordinances, State Laws, and'I�Rules and Regulations of the San.Joaquin Local Health District, Home owner or licensed agents <br /> 7 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 as <br /> to become subject to Workman's Compensation laws of California." <br />! Sign¥ed . ... .... :�I:.. -- weer <br /> .1 a ,f <br /> - : . O <br /> 8Y••' ------ :°------- --------------------------- -- - - Title.--............. ........... ----------------------------------- <br /> (if <br /> ------- ------.------------------- <br /> (If other than owner): <br /> ICOR DJWARTMENT USE ONLY <br />} APPLICATION ACCEPTED BY_._ I� ---- . ....... ......,'. :DATE --- 7�-Wiz ..--..-... <br /> DIVISION OF LAND NUMBER. -�I� .-...---... .. DATE. ---- ------- --------- ---- -- - ---- <br /> r ADDITIONAL COMMENTS....-- -' - - .___ .d�.-:-.- <br /> r -- <br /> �� -------- ----------------• <br /> -. <br /> Final Inspection by:...._.. , 7 ----------- -------------------------------- -Date.-- ._` � - ----- <br /> t I (Sm <br /> FRS 21677 RFV. 7/76 3M <br /> F" 1324AN JOAQUIN LOCAL HEALTH DISTRICT `. z <br />