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FOR OFFICE USE: APPLICATION FOR SANTATION PERMIT <br /> y <br /> Permit No. --_7-�-�-{---•Z <br /> -------------- <br /> (Complete in Triplicate) <br /> --------------------------------------------------- p Date Issued _(-�------------ <br /> This Permit Expires l Year From Date Issued i <br /> struct and <br /> l the work herein <br /> Application is hereby made to the eain compliance with Health <br /> District <br /> i tOrdinance permit <br /> to con and ex sting Rules tand Regulations. <br /> described. This application is ma p S TRACT <br /> s JOB ADDRESS/LOCATION .__,__ I }/_ I Y-�i. CFNSU <br /> Owner's Name ------- ----- --TM------- 1—V_M 5 ����T <br /> ------ ----- ----Phone ------------------------------------ <br /> '� jr ---- ----- <br /> Sr #V MAN------W"Cr. -.. city RQ <br /> 4ddress - � - h e -------------•--------- <br /> T Lt- _ License # Phone <br /> C ntractor's Name .- _ Y_ - R 3 ��i�l <br /> InKtallation willfserve: Residence ❑ Apartment House.❑"Commercial ❑Trailer Court ;❑ { <br /> '' Motel ❑ Other ___f" <br /> !! 2S__ Lot Size -" j; "-- -------------- <br /> Numl?er of living units;--_-1----- Number of bedrooms ?----.-Garbage Grinder <br /> Water Supply: Public System and name _ ! �_ �C � � TT- S Private E] <br /> Character of'soiI to a depth of 3 feet:'., Sand'El Silt❑\ Clay ❑ Peat,❑ Sandy Loam ❑ Clay Loam ❑ <br /> tt Fill Material =_ E----- If yes,type ------------' <br /> Hardpan ❑ . Adobe ❑ , <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: {No septic tank or seeps it permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] 7 <br /> SEPTIC TANK: Siie_ _A_J.0_X__- -------- Liquid Depth �li <br /> " r �MaterialCV_ C ^No. Compartments _- —=--- <br /> Capacity � --- Type - - -�- V <br /> �•_ -------Foundation ---------------------- Prop. Line ---------------------- <br /> Distance to, nearest: We11 ______- -____ <br /> Y Length of each line------------------ ------ Total Length ----_-.--------------------- <br /> LEACHING LINE [ ] No. of Liners ------------------------ g � <br /> 1 y <br /> � 'D' Box ____-______ Type Filter Material ______ _ <br /> De th Filter Material __------:------- - - <br /> --- ----- - -- <br /> " Ul/-- Foundation !� Property Line �_____________________ <br /> Distance to nearest:,Well ______�_____"_-- ""-- - � ----- "�"---"" <br /> i� --- Diame er �__60 Number .--------- ----- '=------- Rock Filled Yes ,K No 0 <br /> SEEPAGE PIT � Depth��-""-�------- 1. <br /> F(LTirP-, 73F–P. Water Table Depth -------------------------------------- ----:Rock Size ------------------- ----- <br /> ------ Pro Line _---------•------ -- <br /> Distance to nearest: W611 __________________ '_____.____.___Foundation --------- -- P <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----=-.-- -- - - <br /> ---------------------- Date --------------------------•---- ) <br /> -------------------------- <br /> - <br /> )-------------- <br /> Septic Tank (Specify Requirements) -------------- ----f----------------------- <br /> -------------------------- <br /> Disposal Field (Specify `Requirements) ------/- --------K-----�0"_-........ _T "" --"" <br /> --------------------- ----------------------------- <br /> k1 :- °' ~: <br /> p <br /> .(Draw-existi g and required addition on reverse side) <br /> that the work will be done in accorda, <br /> I hereby cert) p that I have prepared this application and nce with San Joaquin <br /> s of the San Joaquin Local Health District. Home owner or lieen- <br /> County Ordinances, State Laws, and Rules and Regulation <br /> sed agents signature certifies the following: <br /> "I certify t t in the performanc of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to b e ject o Workm n' pensation la f California." <br /> Signed <br /> Pr(C E USC ,wner r� - <br /> '= a <br /> - Title ..... <br /> lrnis'i' <br /> "([f other than ow er} <br /> 7FR DEPARTMENT'Ll ONLY <br /> -- .---. DATE ... ' 19_,��---------- <br /> APPLICATION ACCEPTED BY "_+. --- ------------------------ ----------- <br /> -: <br /> BUILDING PERMIT ISSUED ---------- -------------------------------------------------------- <br /> -----DATE --------------------------------------•--- <br /> ADDITIONAL COMMENTS -r--- ---------------------------------------------------- <br /> - f <br /> ------------- - - <br /> f ____---__4 __ ________________________y.____-- �A_k_--------- <br /> ----------------------------------------- __ <br /> ftDate <br /> Final Inspection <br /> y ! <br /> SAN 'JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />