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Opt tt US APPLICAT ON FOR SANITATION PERMIT <br /> . ................................................. (Complete In Triplicate) Permit No. ..................... <br /> ............................................... This Permit Expires it Year From Date Issued <br /> -DaW Issued'...? <br /> r <br /> Application is hereby made to the Son Joaquin local Health District.for-:a ;permit"to construct and install the work herein <br /> described. This application is made in compliance with.County-Ordinance-No. 549 and Okifltrng-Rules and Regulatlonss <br /> .I08 ADDRESS/LOC r QIq" .'7..- -r��r:yf T......... :...:..CENSUS TRACfi ... <br /> Owner's Name ... ��.� f ��. ....... ...................................Phone <br /> Address .� �/:'� . �r ....---- - ' _:.._4` ..r..'. ` �t.Cifi/ #.............. ..................... I <br /> Conlraetnr's Nance !-.'4 i :. .... .....•, --� -.License # .��. o .. <br /> Installation will serve: - its dance partment'House fl-Commercial OTrallerCourt C] 1 <br /> Motel❑Other <<; <br /> Number of living units:......".... Number of bedrooms Garbage Grinder Lot Size •........................................... <br /> Water Supply,'Public System and name ...................... . .. .......� �........._._.._.. ----- ..._Private <br /> Character of sail to a depth of 3 feet: Sand E) Silt❑ ' Clay Q,,,.;Peat.o Sandy Loam 0. Clay loam❑ "= <br /> i - Hardpan® Adobe❑ Fill Material .......If yes,type............................ . i <br /> (Plot plan, showing size of.lot, location of system In relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION: (No:septic Conk or seepage pit permitted If .public sekdiL is available-within-200 feet,( �1 <br /> PACKAGE TREATMENT' [ ] SEPTIC TANK f 1 ?Size.._.... '...........--------- <br /> ..E._.................... Liquid Depth .......................... �. <br /> Capacity.A 1 W ..... ......... aterial..........'' ....... No. Compartments _.. : .... <br /> y, -... -�. <br /> Distante to nearer}: Well _...l.. ,_...................Foundaition ..�d............. Prop. Line ..� ....... ? <br /> LEACHING LINE [-] No..of.Lines .. .------••-------- Length of each l[ne..7 �............... Tata! length L��. ..! <br /> °D' Box ....... Type Filter Material Depth -Filter Material ..�L� l........................... <br /> ;Distance,to nearest: Well ........................ foundation ........................ Property line ......................... <br /> SEEPAGE PIT . O Depth :.................. Diameter -------_........ Number ......:.:�_.t.._..__......... !tack Filled Yes 0 No Q � <br /> Y � <br />' ;Water Table Depth ................................................Rock Size <br /> Distance to nearest, Well ........................................Foundation .................... Prop. Line ...................... a <br /> : <br /> REPAIR/ADDITION(Preva Sanitation Permit ... Date ...---) <br /> SepticTank (Specify Requirements) ...................... ............... --....... _.......................................,....... ............................ ! <br /> DisposalField (Specify Requirements) ... ••-••-............... •................................ ......._..-••--.........A_. ..........----..................................................... <br /> ........................................Rj ....................:............... .....................................................................-......................._............ <br /> ............................••• ►.... ..... ............................................................. ...................- •..... <br /> :. ...... .... <br /> # (Draw existing and required addition on reverse side) <br /> ! hereby certify that 1 have prepred this application and that the worts-will be done In accordance,"Is Saes Joaquin � <br /> County Ordinances,'State Laws, and Rules and Regulations of the San ,Joaquin Local Health District. Home owner or licew <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 toll[ kmanCompensailon laws of California." � <br /> Signed Le-/..' o! ..... -- Owner :.:.:............. .......... <br /> �/ ; <br /> By .................... •..................---........... I........................ Jit a ...... .....-. .......... . .. . <br /> (If other than awned <br /> FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. <br /> .... .. ....................................,......DATE.... ...r--�✓1-...�-- -. .... <br /> BUILDING PERMIT ISSUED .DATE ..................... ... . .......... <br /> ADDITIONAL COMMENTS . ....................................:......................:.........-• ----............ <br /> ..._...........................................................................-----......... I <br /> ....................._........--......... ....---"--........_ ..-.-.... ....-.-............. .......................................................................................... <br /> Dcete . <br /> Final Ins action . 7 .. <br /> Eli 13 2h 1-68 Re's. `5K SAN JOAQUIN LOCAL HEALTH DISTRICT 314'1 <br /> __ <br />