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EOR OFFICE USE: <br /> ------------------------------------------------ APPLICATION FOR.SAPIITATION PERMIT '/ <br /> (Complete in Triplicate) Permit No. _/--�`-_✓3-�3 <br /> --- <br /> L 'J_- This Permit Expires 1 Year From Date Issued Date Issued ----5'.�_".�7 <br /> 1 x +1�� <br /> Application is hereby made to the San Joa juin; Local Health District for a permit to construct and install the work herein <br /> described. This appli5ation_i /made in_com Ince N ith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS LOCATI '- _-_E_-gjn-- ----S�--------- -v -- ---At)------------------CENSUS TRACT ------ <br /> .. ........... <br /> Name -- --- - ----Ll--��-- ►�-V-/ L _ / Phone <br /> Address1 / ------- -------------------------------------- City. __._ � /V -- .---------- ---------------------------•---•-- <br /> Contractor's Name .- ---- ® ER_ License # ------------------------ Phone --------------_------------- <br /> Installation will serve: Residence [JApartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ---_ -__ - -------- ------------ <br /> Number of living units:------l_---- Number of bedrooms ; Garbage Grinder L49._ Lot Size --- <br /> Water Supply: Public System and name ---------=------------•-------------------------------- ------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ -Peat❑ Sandy Loam e Clay Loam;❑ <br /> Hardpan ❑ Adobe ❑ Fill Material __1 '_l�__ If yes,type ------------___--_.______ <br /> CS <br /> (Plot plan, showing size of lot, locatio of system in relation to welfs, buildings, etc. must be placed on reverse side.) I� <br /> NEW INSTALLATION: (No septic to seepa pit permitted if public sewer is avail ble within 200 feet,) <br /> PACKAGE TREATMENT [ ] SE [ Size----------_------------------------.------------ Liquid Depth _____________------______ <br /> Capa - terial------- ---------- No. Compartments -----.---------------- <br /> Di -- -- - ._.-----Foundation --- -- - - --------- Prop. Line ----------------_---. <br /> LEACHING LINE [ ] n f each line----------------------- Total Length -_______________________ <br /> ox .t I --------------------Depth Filter aterialr -----------------------------•------------- <br /> ta I --- -------------------- Foundation -------------- ------- Property Line ----------------------- <br /> SEEPAGE PIT [ ] Dep _____________ ____ Diarr eter ---------------. Number ____________________ ------- Rock Filled Yes '❑ No L7 <br /> Water Table Depth ------ ----------------- ------------_-----Rock Size ------- ------------------------- <br /> Distance <br /> ------- -Distance to nearest: Well ______________•-______----___--•-.Foundation _ __-'___ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ___------------------------------- Date --------------- _______.----_•__) <br /> SepticTank (Specify Requirements) ------- -------------------- ----- - - ----- -------- ----- ----------------_------------ ---.-------------------------- <br /> P, 't`�elcl tpeld (Specify 'Requirements) 'IC-1-�7- Ll.1V.�-- �RQ . <br /> _•. ,._.`a--�} _„ fit-, ( F t� A _. / --` ---- . ----- <br /> ---------------------- ----- - -------- -------- ------ ---------- -------- ------ ------------ -- - ----- - -- ----------- ---- -•--- <br /> - - --- - ---- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify%]ot I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord inancef,, State Laws, and Rules and Regulations of the San Joaquin Locat Health District. Home owner or licen- <br /> sed agents signature''�certifies the following: <br /> "I certify in pe o nc of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to be e s A to k n Compensation laws of California." <br /> Signe --------a` ------ --- ----------------------------------------- Owner <br /> By •=------------------------------ ----------- ----------------------------------- L ----- Title ---------------------------------------- <br /> -------- ------------------ <br /> (If,other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> AP.PCICJITIONACEPTf© BY - _ ___-- __(. _ dAtE <br /> -------- <br /> ---------------- <br /> U1 <br /> BL.., - � <br /> ADt?I AL CC►�IMEN7S __ --- ----------------------------------- , <br /> r--------I------------------------------------ -. -- -- t - --------- - --------- ------ <br /> ---- - - <br /> - --------- <br /> Final Inspection by: _, /rl�l --------- �Y <br /> --- -- -- -� - ----Date -- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 5► p1- b&itev. 5M C� <br />