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05/04/2003 013: 01 469-8 JEFF ROGERS T,,,JIG PAGE 01 <br /> FOR OFFICE USE, _ <br /> E � APPLICATION FOR SANITATION PERMIT LDate <br /> OFFICE USE: <br /> _......................................--......... <br /> ..__..._.......__..... -. <br /> ,f..4........._.........._ (Gmplele In Triplicate) No.... -:/� <br /> "" .................. Frei" Das*P ... <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein dost (bed <br /> � �� is made in co plionce with Caunry Ordinance No. 549 and existing Rules and Regulations: <br /> _j, <br /> 8 ADDRESS/L TI ...... , p CE 5 S TRA <br /> f. _ <br /> ll'''' <br /> Owner's Name.. .. .....W. �C.... TRACT,..... <br /> . ....... .. ....... .. .............. <br /> .. P : . . ansAddress..... 5T �! . ...Conhoaor's Name.....MI-OL- Ti _.7 .Y... <br /> Installation will serve: Residence !�. . <br /> Apartmant l... <br /> House❑ commercial � Trailer Court ❑ <br /> Motel ❑ Other................................. <br /> Number of living units:..� N <br /> '1�- umber of bedrocross..� Gar <br /> bago GrirEdeP"ti♦�..'lof Size------..._..�...............---....:._. ....... .. <br /> Winer Supply: Public System and name................. e : <br /> ............... ....... ...©. t....................................PrI vote <br /> Character of sail to a depth of 3 feet. 11Sand Silt Jl Clay ❑ Peat❑ Sand Loam Clay,Loam ❑ <br /> Hardpan❑ Adobe Fill Material.. .........lf yes, type <br /> .......... .........:....... . <br /> (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc• must be placed on rcvwso side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within'200 feet,( L <br /> PACKAGE TREATMENT [ J SEPTIC TANK [ Zf� Size-...................................... -----Liquid Depth..........._. _ <br /> Capacity... ., ype...................... `.No. Comportmerits.... <br /> it <br /> Distance to nearest: We11........, 10..... ..Foundation-10...--. 'Prop. Lino.X <br /> --------------- . <br /> ...-......... <br /> .....: <br /> LEACHING LINE [ ] No. of Lines...-------. ................Length of each II%. w..---.......Toto] Longth.MQ„_--•-- <br /> ................_ <br /> 'D' Box.... . .14.. r <br /> Type Filter Material Filter Material <br /> Distance to rest:Well.......-.]�. .......... Founsfati 'C 3 . Property Une.............7! <br /> �rstep .. ....._. . ................-' <br /> SEEPAGE PIT I 1 Depth..�t7,. <br /> ...Diameter... .........Number...(. -------� r �. Rock Filled Yes No❑. <br /> ......................_ <br /> Water Table Depth................1.Qo....._.....---.._. . a <br /> . _.. ....Rock Slzs..........1./E......".:��7E.............. : <br /> Distance to nearest: Well..........LI,-.5,:t._... <br /> Foundation._.....!? .. ......:Prop. Una...._.................... <br /> REPAIR/ADDITION (Prov. Sanitation Permit#.............. ........... <br /> .._Date.................. . .. <br /> Septic Tank )Specify Requirements)...•......................... ........ <br /> . . ,.. c.......... <br /> Disposal Field (Specify Requirements)..................... ............._._.....i.............................. - . <br /> ....----.._...._......................................................_-..........................._....._.. <br /> _.........................---------.._...... ...----...................._......_......... <br /> ...-------....._...............-.`.........................._..------------------------.--------------.............................. <br /> [Draw existing and required addition an reverse side) <br /> I hereby certify their 1 have prepared this application and that rho work will be done in accordance with Sen Joaquin County <br /> Ordinances, State laws, and Rules and Regulations of the San Joaquin Locoi Health District. Home owner or licensed agents <br /> signature certifies the following: r f•” '" <br /> "I certify that in, the Performance of the work far which this Permit N issued, I shall not employ any person In such manner as <br /> to becis sub • Werkm CenspensaNen laws of California." <br /> �� tt�� , <br /> Signed......-V`!.. ' ..........._.......Owner <br /> By.......................*........................................................--.....................Title............._..............................:........................... <br /> (If other than owner) <br /> KIM DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY._..... _. -. . .. 1-1- DATE;+.....VI- ..Z.B..............._....... <br /> DIVISION Of LAND NUMBER.------ . v.. .......... <br /> p �...�•r-. -. '- ..._ ._ _�.r � ..... p <br /> . ...�...C.........................................................................ADDITICNALCOMMENTS............. d � . ........................... <br /> .............................................. ...............................................................................I.........................._...................................._..... <br /> .. <br /> .r:c.......:....... .................................---------.........--------...... ......boro--b... .. :_r.>............................ <br /> Final Inspection by,........ <br /> EM 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ru nen sv.rna sw <br />