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<br /> t FOR OFFICE VSE: t �
<br /> APPLICATION FOR SANIT. VON PERM
<br /> ................................... ------. g
<br /> (Complete in 74ficate) i,2rF,7it F,Ic,: ..::__. .-Y•f
<br /> .................. -- - 7 111511'ermlt Expires 7 Year From Date Isaued Date Issustl
<br /> Application is hereby mode to the Scm Joaquin Local Health District for a permit to construct and Install the work herein
<br /> described. This applicatlor, is made in compliance with C0fy Ordinance No. 549 and axlsting Rules and Regulations:
<br /> JOB ADDRESS/LOCATIOf � y�J
<br /> .......------CENSUS TRACT
<br /> Owner's Name
<br /> Address ............. ��� � /.. / r'�� ..c � " .. _. " -.......P ane _..._......... ... ................
<br /> Cify ...............................
<br /> f � Llc :� Phone -
<br /> Contractor's Name •`-••••__,
<br /> �``�'a
<br /> t �--'�'-.. .......:.......•-•.........---
<br /> Installation will servo, Resldenceg Apartmenf House 0 Commercial ❑Trallar Court
<br /> Motel ❑ Other----•-•. r_._:_�.......,
<br /> Number of living units,.-- Number of bedrooms I
<br /> Garbage Grinder Lot Size
<br /> Water Supply, Public System and name ............................. Private
<br /> Character of soil to a depth of 3 feet, SanclO Silt o Clay 0. Peot CJ Sandy Loam Clay Loam.0
<br /> Hardpan 0 Adobe ,[] Fill Material ............ if yes,type......................
<br /> IPlot plan, showing size of lot, location of system in rotation to welis, buildings, etc, trust be placed on roverse side,)
<br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If btic sewer Is available within 200 feet,)
<br /> PACKAGE 'TREATMENT ( ] SEPTIC TANK� Slae_�� lY `� �' 5-
<br /> ...
<br /> Capacity +� Type -'._ �.__ Material-...,<n = -_ No, Compartments .�._._.. -
<br /> Dlstancp to neo s : Well _._.__•. Y Foundation .___..r ......_.... Prop, line _5., ._._:......._
<br /> ............
<br /> ..
<br /> LEACHING LINE r' No, of Lines ......... ....._______.. Length of each line_.• --. ,�...,___, Total Length _.. ' .f�d._�,
<br /> 'D' Box TYPe Filter Material =.-_-'l,l'.-Depth FIi /
<br /> tar Material ------ ---------•-•-----------•....--•----•.
<br /> Distance to noarost: Well .. Foundation Property Line ...- _�_
<br /> SEEPAGE PIT ( J Depth .................... Diameter .........- __:_ Number:'.:..-..'- ---=--•_- Rock Filled Yes "" No
<br /> , . o
<br /> Water Table Depth Rock Size........ .
<br /> Distance to nearest: Well ........................
<br /> ...:......,..:..Foundation ____............_... Pr4p, Line
<br /> ......................
<br /> REPAIR/ADDITION(Prev. Sanitation Permit#
<br /> Datb
<br /> Septic Tank (Specify Requirements)) ..__.... -..................................................................
<br /> Disposal Field (Specify Requlraments) ........-...............................................................`':.. i
<br /> ---------------•-......•-------.............
<br /> ._..... ............
<br /> .............................................. .........I...._. . ....� ... .....:. :.:'. ....................w........................
<br /> .................. -----•-• .............•----•......•--.........----------... ------------ ----- ....................
<br /> ](Draw existing and required add ltiora_on-raverse-sido)r,.
<br /> I hereby certify that i have prepared this application and that the work will be done-In accordance with Son Joaquin
<br /> County Ordinances, Stote Laws, and Putes and Regulatlens of the 5ctn Joaquin Local Health District. Home owner or Veen-
<br /> sed agents signature certifies the following:
<br /> "I certify that In the performance of the work for which this permit Is Itsued, I shall not employ any person in such manner
<br /> as to become subject to Workman's Compensation laws cif California."
<br /> Signed ---•.....................•• ---- -- ------•- Owner
<br /> x --{}.
<br /> By ---------------._...,.,:::.:.. - �f�a� .r.---.. . ...`�cS:� .Tltie �-- �J`i(,•e��o� '
<br /> (if other than owner)
<br /> FOR DEi'ARTMIENT USE ONLY'-
<br /> APPLICATION
<br /> ACCEPTED BY ._,•.._ _'„ "" • `. �,
<br /> :..:.......:. ...� ` DATE "�'�. .................
<br /> DING PERMIT ISSUED "'
<br /> DATE
<br /> ADDITIONAL COMMENTS .......
<br /> ................
<br /> .......... ................ ............ t ..... ' ' ...........•.......-...................... ....•..................,........•............•.
<br /> ._ ..... ._...
<br /> -
<br /> Fin ... ._. - •- ....... .... ---••-.....------ ......---- .......... ---
<br /> al �-- - ......
<br /> Inspaction by "" ,,.�_ Da e
<br /> ems. .. ._.,. --
<br /> t SkN InAO111M InrAt ur-A,ru r
<br />
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