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<br /> FOR OFFICE USE:
<br /> APPLICATIONFOR SANITATION PERMIT FOR OFFICE USE:
<br /> r
<br /> ........................... ..
<br /> (Complete in Triplicats) Permit No .`A.A :.
<br /> .......................................:. . 71. ?
<br />"
<br /> 3 Date Issued
<br /> ................... . •••••• r`
<br /> '
<br /> This Permit.Expires-1 Year From Date Issued rl,
<br /> II x
<br /> 1F •'
<br /> '`Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein describeda'ie'�j.: ='
<br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: `
<br /> y
<br /> -JOB AD.D_R,._E..S:.S./ OCATION.-...(-..._.e.P... .... . .. ,._I . ...-... .
<br /> ........ ..... ....... . ..
<br /> ..CENSUS � -•-•---
<br /> --
<br /> ermOwna. e:._. Phe. ...
<br /> •Ad,dre .... - .c.�..
<br /> .. .Y
<br /> -: City- -2 -... __(U ..._..-Z �'--3 6�
<br /> Contr
<br /> Install tionswill serve. Resia_ece❑ Apartment House Commeecial # Trailer Court Phare.............................':.. g'
<br /> i Motel © Other... .-,f-.�..t�/P'.e.............
<br /> Number of living units:...............Number of bedrooms............Garbage Grinder..........-•Lot Size............... 5
<br /> Water Supply: Public System and name............GcJE�L -Private
<br /> • s
<br /> ............ ................. .,............--....................................... rives e'
<br /> Character of soil to a depth a- 3 feet. Sand❑ Silt❑ Cloy(] Peat r] Sandy Loom❑ Clay Loom
<br /> Hardpon❑. Adobe p Fill Material-- .-----...If yes,type........... .................... p% a
<br /> (Plot plan:showing size of lot, location of system in relation to wells, buildings,etc. must be placed on reverse side.) 8C '
<br /> NEW:INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 204 feet,)PACKAGE ;
<br /> TREATMENT SEPTIC TANK ..._.-_.Liquid Depth ..........:....._ '
<br /> I1 I1 Size.................... - R
<br /> Capacity......................_Type....--•................Material.------ ........ ....No. Compartments..............
<br /> i
<br /> Distance to nearest:•Well: .:._.:..-•...............................Foundation
<br /> .:.--•-•--------..........Prop. Line-----
<br /> 1
<br /> LEACHING LINE'% I No, of Lines..............................Length of each line..........................._-.Total Length....................
<br /> 'D' Box.........:__Type Filter Material..s.................. Depth Filter Material.. ___............-_____
<br /> _
<br /> ,.Distanco _
<br /> to nearest.Well.......... `:..:., Foundation.... Property Line..........__
<br /> SEEPAGE PIT I 1 - Depth._..... ': .cDiQrneter..... Number................................ Rock Filled Yes❑ No'[]
<br /> Water Table
<br /> Depth... _... Rock Size
<br /> a. :' _..
<br /> !
<br /> :C7{stce'15, Breis Well...... ................................Foundation....-_........ .........Pro Line._.._.
<br /> l REPAIR/ADDITIOWIPre .sa f6r,tc t i'op pQrmit#...........:............. .:::--:_::::::::::.Dare--:
<br /> SepticTar jSpeel ai tiraments) ..........................................................................................................
<br /> #...
<br /> Disposal Field (Specify Requirements)...:................:..... ............--......-.. ....
<br /> ... .-•...............
<br /> :.. ------------------
<br /> { x: (Draw existing and required addition on reverse side) i
<br /> hereby cortlfy.that! have prepared,thl application and that the work will.he,clone In accordance with-Son .Jacquin'County r
<br /> Ordinances,:.State Laws, and Rulis:and;Rogulatiion$ of the San Joaquin lacabl:ealth District. Horne owner or7lcensed agents
<br /> siginature cortifies the following:
<br /> '.'I
<br /> Corti at In the performance of the work for.which thls;,permit is'issued, I-shall not employ any person in such manner as
<br /> to becorna subject to Workman's Compensation'laws'of•Callforma. '
<br /> _-- ,
<br /> Slgned Owner
<br /> t,
<br /> Title. ........... ........
<br /> (if other than owner)
<br /> _,
<br /> FOR DEPARTMENT-USE'ONLY
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<br /> APPLICATION ACCEPTED BY.............. . `---••-----.-,.........-------•-•- -- Z !�
<br /> TE..,7.7,17- - -----------
<br /> DIVISION OF LAND NUMBER...................................................................... .........................................
<br /> .............DATE..... ....._..-..-. ..:...
<br /> ADDITIONAL COMMENTS-----
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<br /> ...............................................I
<br /> :
<br /> .................................. ..........-...........-__.._._............._..___..._.._.._.........._..................-
<br /> ....................................•-,...........'........ .
<br /> Final inspection by-------------•••-••-----------:10_... -_ ------ .................................Date...... - ._...__.......-
<br /> EN t]74 SAN JOAQUIN LOCAL HEALTH 0ISTRICf F&S 2)677 Rev.7176 3M
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