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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> r-0151------------- <br /> C/1� - Permit No. <br /> Dt tai (Complete in Triplicate) <br /> -----------------------------___-________-__- ---------------- This Permit Expires ] Year From Onto Issued <br /> Date Issued -_ --a ---- <br /> Application is hereby made to the S noaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made *n compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 1 JOB ADDRESS/LOCATION ./.�_�_---- - -- — lef--1 Ak- ----------------------- -:----CENSUS TRACT ------4W------------- <br /> Owner's Name, a'-V_ W. � -� = Phone <br /> Address P2"___1411---- p d�+- -% - City _. ? <br /> Contractor's Name --- - ------ _- _ - --�.� ------------------------------- License�#oiler Court <br /> ------------------- ---------- <br /> I J N �. <br /> Installation will serve: Residences,ApartmeWHouse❑`C,ommercia ❑ ,❑ <br /> Motel ❑Othirr --- --------- - `+` ---- <br /> • f <br /> Number of living units:- :-r- Nu' ber of bedroom A-I _xb9ge Grinder, -/W-__ Lot Size --------_----- <br /> Water Supply: Public Syste and n me ------�-------------------------•-•-----Private ❑ <br /> �' E3 _nh Loam Clay-Loam <br /> Character of soil to a depth of 3 fee Sand'❑ Silt❑ Clay��-� Peat❑ Sane � ❑ y' ❑ <br /> { ❑ Adobe Fill Material ------------ <br /> If ye typ <br /> ------------------------ <br /> Hardpan <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must .be plbeed! on reverse side.) <br /> I 1 ' <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted f public sewer is available within,200 feet,} <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[.].. ,.._- 4.h. . _Size ------------- ------------------ ------- q ! pth ---------------------.----- P <br /> - ----- T -------------------- Material---------------------- No. CompaDments Al <br /> Capacity ---- Type r P�� --------------- ...... <br /> .-- <br /> Distance to nearest: Well ------------------------------ ----- _ rl p,, <br /> --.Foundafiion ____----_--- -- -_ Pro Line --••------------------ <br /> LEACHING LINE [ ] No. of Lines ------ ----------------- Length of each line----------____ rs I <br /> - ------------- Total Length ------------------.�.....-_ 1 <br /> 'D' Box .____.------ T#pe Filter Material --------------------Depth Filter Material •- i <br /> -------- ------ <br /> SEEPAGE <br /> Property Line -_--------..._.__,._.--- <br /> --- -- -- Diameter -------- ------ Number ____----.----_-------------- Rock Filled: Yes No 10 <br /> SEEPAGE PIT [ ] Depth --------- � ❑ <br /> Water Table Depth ------- # <br /> ----------------------------•------------Rock Sizes-------------------------------- <br /> Distance <br /> ----- - ----------------------- <br /> Distance to nearest Well ----------------------- ---------------Foundation ----- -------- ---- Prop. Line .._------------------ <br /> ! REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------------------------------- .------- -------------------- <br /> ----. ------------ <br /> Septic Tank (Specify Requirements) ; �-.._ - <br /> �- JJ <br /> Disposal Field (Specify Requirements) ---- 1 --------- t------- - = <br /> ----------- ----------------------=--------------------- <br /> ------------------ ----------------------------------- -I-------------------------------------------------------- ----------------------------------------- <br /> ------------------------ - - - ---- <br /> (Draw existing and required addition on reverse side) ' <br /> I hereby certify that I have prepared 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 iDistr ct. Home Aw�`ner o cen- <br /> sed agents signature certifies the following: P 4%— � <br /> "I certify that in the performance of the work for which this prmit is issued, I shall not emply any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ?Othan <br /> ------------- ------- ------ -------------------------------it Owner <br /> BY ------ --------------- ------ - - ----------------------- --Title -------- <br /> ------------------------------ <br /> (If owner) <br /> FO PA1tTMT USE ONLY <br /> APPLICATION ACCEPTED BY -- �--- ------- =-------------------. DATE ' y 4 _4 <br /> - -- -- -- - ----- <br /> BUILDING PERMIT ISSUED ------- ----- ----- ---------------------- DATE .-------------------- <br /> AD ITIONAL CO MENTS -----_---- _ -- ---- <br /> �C �� / t p&�7- � �-.. — -----�{�� <br /> - NJ <br /> - - <br /> /� <br /> f - -`---- Ls /' --------- ��a'f� <br /> - -- tC - 1 <br /> E �J # ! --- (- ----------- --- - ------- <br /> - ---------- <br /> y a <br /> Final In y cNn b - Date s, - �_= � <br /> O. UIN .LQq-4L HEALTH DISTRICT S <br /> _l <br />