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.. . ... ""• APPLICATION FOR SANITATION PERMIT <br /> .................................................. <br /> (Complete in Tripilcota) <br /> ................................................... ..� <br /> Date Issued <br /> ...__._•..................I.•.•.....•_....., This Permit Expires 1 Year From Date Issued <br /> the <br /> in Local <br /> ealth <br /> rict <br /> rmit to <br /> 6 and <br /> l the <br /> described Thislication Is happlicat application ode In compliance witfh CounttytOrd Ordinance No. 549 and existing Rulestalnd Regulatons,sin <br /> JOB ADDRESS/LOCATION "S. ..... . .. .. .......Ctf.�C. . .ir!s LCL.......... .............0ENS US TRACT .......................... <br /> Owner's Name ...... .�.1G•+......... ... .�:LGL� a =t`.. ....................... <br /> Address __.l r.>.a............ s:...... ........ _-.... City <br /> 24.,Z, .. Ph.o.n..e..• • . <br /> Contractor's i . .-.-.•..._ <br /> c <br /> .•• <br /> Installation will server Residence OApartment House Commercial ❑Troller Court ❑ / <br /> // Motel ❑Other ............................................ ��/ <br /> Number of living unitu....,1..... Number of room .. _.......Gfarb�age Grinder ..-�'- Lot Slzs - :• •=•• - -•• •• ••••••-•••--••• <br /> Water.Supply: Public System and name �_....._................... ....................Private❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ day Loom ❑ <br /> Hardpan❑ AdoboX FII(Material ............ If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to walls, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit perraitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK( )Z�OS1-146.4.................... quid Depth ..........................0 <br /> Capacity .................... Type .................... Material...................... No. Compartments ...............--.gyp <br /> Distance to near/eesh Well ....................................Found tion ...................... Prop. Line ..--..................Z <br /> LEACHING LINE ) No. of Lines ...1.................. Length of each line..... ............... Total Length •.Sf.. ......•••••. <br /> 'D' Box .:457...... Type Filter Material 4 '......Depth Filter Material .ZY.......................7.......� <br /> . , Distance to nearest, Well Foundation ZC. ............. Property line .-s ••••••••••••- <br /> y / <br /> SEEPAGE PIT Aj Depth ac-S-....... Diameter .1 .:........... Number ......1.................... Rock Filled Yes No <br /> Water Table Depth ... ..............................Rock Size .............. <br /> r r <br /> _ Distance to nearest:Well ......... ...........................Foundation 4-............. Prop. line ..5._.......... <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ..................................I <br /> Septic Tank (Specify Requirements) .....................................................................--....._......_........ ..........._ ._ ......._................ <br /> Disposal Fiela (Specify Re ulremenfs) f� L'- -.- �j. .. .....- 6t j.•........-•- - <br /> �i <br /> ..----.......................G�:.-!c- -K..---.... -d'2- -...j....... �.�.v�` �. .�... .... �k •t`. ...... e .'. Srxa .........---.. <br /> ._.......... . ................................................................... ...................•-............................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with Son Joaquin <br /> County Ordinances, Slate Laws, and Rules and Regulations of the San Joaquin Local Health District. Hems, owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is Issued, 1 shall not employ any parson In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .......... ........... ........... ... ...... .......... Owner <br /> `/ _ �. title ...... /L <br /> By .......... .... Cc: �G r�Gp cd .............................. <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .................................. DATE ...r:..'. ..2...::.:b............. <br /> :r: <br /> BUILDING PERMIT ISSUED ..... .../......... . ... ..............................DATE ..__._................................. <br /> . <br /> ADDITIONAL COMMENTS ../L. ../tJ..7. 6....>�y O! ..:......E '........................................................... .........:........................... <br /> _....._......._...... .............. ...... ........................._..................................................._ .................................................. <br /> ........................... ................................................... <br /> ............................................ .............................. ... ..... .... .--.... .................. <br /> Final Inspection by: .... .. .. ..... . ..... ..............................................................................Date .�✓��.� . _........._..--- <br /> ..... <br /> EFS 13 24 1-68 SA p( JOAQUIN LOCAL HEALTH DISTRICT 8/7� 3M <br />