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FOR OFF,,:E USE: APPLICATION FOR SANITATION PERMIT <br />............................................. .......... (Complete in Triplicate) <br />........................ This Permit Expires I Year From Date issued <br />FOR OFFICE USE: <br />Permit No._ <br />Date Issued.__T!-/:j!7?.*C_ <br />................. ------------------ ....... ............ <br />0 permit to construct and install the work herein described, <br />Application is hereby-m-acle to the Son Joaquin Local Health District for ting Rules and Regulations. <br />1, ce with County Ordinance No. 549 and exist <br />This application is made in'comp ton <br />....................... <br />...CENSUS TRACT ---------- <br />JOB ADDRESS/ LOCATION .......... Phone ............... • ................... <br />. ............ ......... F4 <br />Owner's 4 ------------- Zi <br />City... ......... ....... .......... <br />Address ------------------- Phone ---------------------------------- <br />LicensF ----------- <br />A ...... <br />actor's Name.-:--- ........ ��_ 4__ <br />-� - - 4�4 jai E] Traitealer Cdurt-Q� <br />Co,ntr 1�_ ..... Commercial 1--, kesidence 9/ Apartment House 0 <br />Installation will serve:• Motel M Other ------------- .................... " --------------- <br />--------------- ------- ------- <br />............ Lot Size Size.._...__.... <br />:.-___._•..--•--.- of: living units: -------- Number of bed rooms_-;�!__..Garba�ge Grinder,. <br />Private <br />-------------- <br />blic System and name-:,-._-.,. ----­------ .............. ......... <br />Water Suppiy:_�u Clay Loom E) <br />Character of soil to a depth of 3 feet: S6nd Silt C] clay Peat F1 Sandy Loam El <br />Hardpan .. -- ------ If Yes, type --- ------------------------------ <br />n Adobe _g Fill Material- <br />e `6tc..musi be placed on reverse side.) <br />(plot plan, showing . size of lot, location of system in relation to.�t% _1�� n sewer is le within 200 feet) <br />age pit perm-Iffed if publlici sew <br />s <br />b <br />ng" <br />sev� r <br />INSTALLATION: (No se tic tank or seep <br />NEW INS ---------------- --- <br />.. ...... ....... <br />PACKAGE TREATMENT SEPTI T_A�NK. <br />0 ------------------- <br />N <br />pe. .,-.No; compartments <br />---- - ----- <br />capacit Y ------- .. ......... Prop. Line.._----------------:.__. <br />-------- <br />t est. 0 <br />crest. Well.... ------------ ....... ------ Foundation <br />Distance t t Total Length....__7_3_'�?__ ------------- ------- <br />No. of Lines..... -------- each h of e <br />LEACHING LINE: .. _ . - -�;Mqterial._: ------- 41 --- -------- --------------------------- <br />'5,e' Depth �jlt7e <br />'D' Box I... -Type Filter Material__ ------ i­�. . <br />I Property Line_.____. ............... <br />n ------- <br />.1clatio <br />Distance to nearest. Well. ...... ....... <br />k Filled Yes [I No El <br />tf <br />Roc <br />mber -------_-------------- ;Z, <br />Depth.-----------• -- Diameter -------- ------------ Nu J <br />SEEPAGE PIT <br />h <br />Rock Size----- <br />`" <br />iz6----- <br />Water Table Dept..--------------- ------------ V <br />----- <br />-- <br />--­---------- <br />------- <br />------ <br />.:7ibuncation_--_---- -- -- -------....Prop. tine.--------------• <br />Distafice to nearest: WeiI----------------------------Date..........!•.......... --------- <br />REPAIR/ADDITION (Prev. Sanitation Permit#•.................... ................. 6 ......... <br />--------- - ................ <br />---­---------- ---------- <br />Septic Tank (Specify Requirements) --------- ---_--------_- — <br />.......... ------ -------- ---------------------------- <br />Disposal Field (Specify Requirements)_...._-- ---------- __! ----------------- <br />--------_- ................................. . ------------------------- I ........ - <br />.................... ...... * ........................... ................. ----------------- ------ <br />L..... ­­ ------------ : ............... .......... <br />........................ ............... ................. ............ <br />............................................................. <br />............ (Draw existing and required addition an reverse side) <br />ithe work will be done in accordance with Son Joaquin Cou4. <br />I h;reby certify thal'I have Prepared this application and that <br />ations e_San Joaquin.Local,Health, District.'Home owner or licensed..Sgent <br />_of_jh <br />Ordinances,' State -Laws, _ancl_ltules-_ and- Regul <br />signature certifies the following:A.— — 4.. <br />.!1:11__�Luch.m nner a <br />I ued,_11-shall. no A <br />-I certify that -in -;the -performance-of -the..work- for- which -'this perimit-Is- ss <br />a Workman's Compensation laws of California." <br />to become subject It <br />Signed__.. :­­ ...... -_ ----- ------- --- Owner <br />0` ...... .................................... <br />Title- <br />BY--------------------------- --------- -- <br />(if other than owner) <br />R DEPARTMENT USE ONLY <br />E•--------•-.......------ ............... <br />... DATE. <br />........ <br />------ ............. <br />. ..... ........------------- <br />APPLICATION ACCEPTED By ............ ------- <br />---- -- ---------- DATE -----_------------------ <br />........................... ......... <br />DIVISIONOF LAND NUMBER ----------••-----------------••- ----- ----------- - ------ ........ I ....... .... ------------------ ...... <br />ADDITIONAL COMMENTS_ --_------- -------------- <br />- ------------- ­­ ------- <br />--_--------------------- <br />--------------------------- <br />................................................ _m --------- ................ -------- ..................... 1- --------------------- <br />---­------------------------ --1 ................. ­ -------------- ------- -------- I <br />------------- ......... ........................ <br />­_­ ....... ---- <br />------------------ ------ --- -------- Date. . ...................... <br />Final Inspection by: ---- -- -- --------------------------- <br />------------------------------ F&S 21677 REV. 7/76 <br />rw Iq 1A SAN JOAQUIN LOCAL HEALTH DISTRICT <br />