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FOR oFFlce USE. ; - � '- <br /> APPLICATION FOR SANIr'I'ATIO�I PERMIT <br /> _..........:.................:. Permit No. .-77..`73 <br /> (Complete in Triplicate) <br /> ............................... .....I.................. <br /> . - Date issued .4.r.`Y��7... <br /> This Permit Expires ] Year From Date Issued <br /> Application is hereby made to the�San Joaquin Local Health Distric'i-for a per to construct and install the work herein <br /> described. This applicatio Es madeAcompliance with oun�y Ordinance No. 5Q4 and existing Rules and Regulations: <br /> h Z <br /> , �4'ENSUS TRACiJOB ADDRESS/LOCATION G .:... <br /> s Name .-. r._ i... ,�-L�.. Q. ....... :..._ <br /> .....Phone ?;P.3 <br /> Owner' ....�z�. .lr <br /> ..--..../.`?.9.Q.......a.aa e .... City .--.-.-,1 N.rs~. C� ...::---•-...._ .. <br /> Address -- ••-•-----------..._..... .................... <br /> Contractor's Na?ne .�. "- `:-.....License # �-, �Z Phone . <br /> ;...._ �� „.............":...... <br /> Installation will serve:Residents Eg A-Sci-rtff#-6t'House 0-Commercial ❑Trailer Court <br /> Motel ❑Other i <br /> Number of living units:---l........ Number of bedrooms S-..----Garbage Grinder:`__...:._..: 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 ❑ Clay Loam <br /> i Hardpan [] Adobe '[] Fill Material --- if yes.type --- ------------------------>-4 <br /> (Plot plan,, showing size of lot, location of system in relation to wells;•buildings,--etc.-must-be.placed_an_ceverse .side.} <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,l <br /> All } <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size..6r1 �.-7.X 4................... Liquid Depth .............. <br /> I Capacity /2. _ Type k1fCA6 Material...................... No. Compartments .. y,. <br /> f Distance to nearest: Well .:..��f?...- .---Foundation ..Z�s............... Prop. Lina .... ............ . <br /> LEACHING'LINE• [ ] No. of Lines --- .............. Length of each line._--.�G.----- •..---••- Total Length ..M-147_• ..............� t <br /> p ; <br /> D' Bax, ..:.�____-- Type Filter Material V)�.Depth Filter Material .....-..L.��............................ <br /> -ty <br /> Distance to nearest: Well ...rte..-.....•......• Foundation .../�e'_�........... Property Line ........................ <br /> i �• <br /> Rock Fllied Yes No <br /> Depth F _f Diameter <br /> Number .-__-. .............. .. ® ❑ . <br /> Water Table Depth ...................... Rork Size . <br /> .... .... <br /> . <br /> l } Distance,to nearest: Well .......-----•.......................,....Foundation .................... Prop. Line ............................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit j# ........--------------------•....._.__--_--. Date ....._.._...................-.---•) . <br /> i . � � — .. .. r_.... <br /> — _ r� —. ... ' . ........r............ w�_r.......---- r ........ ask <br /> Disposal.,tField(Specifyic Tank 5ecR q Ree u eementsl ...........{.S /_�. .:: ►' ..... ` " •�1 --------------`...........I— <br /> 1p Y a <br /> wa � � <br /> ......... ...................................-.--.-......------------...-------- -••------•-.-- __._............_.._......._. <br /> i .......... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify �that I have prepared this application and that the work.will be done in accordance with San Joaquin <br /> County Ordinances, State }Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or lieert- <br /> 3 sed agents signature certifies the following: t7l 3 i <br /> "1 certify tNot in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject W� rkmapensation laws of California," r <br /> k <br /> Signed � .....�.-.-.. . Owner li <br /> ' <br /> By ......................�.............. .:.. ......4_��--------------------.................--.. Title .... ... <br /> (if other than owner) _ t <br /> . ! FOR DEPARTMENT USE ONLY <br /> K � � <br /> ` DATE <br /> ' .APPLICATION ACCEPTED BY ..........:_;,-----••----..._ .L/.....f..--��..............., <br /> r .:.BUILDING PERMIT ISSUED .........`....--•------------------- ---------.....----:......---------.........---•....--..._.......DATE ..................................._....... <br /> ADDITIONALCOMMENTS ........--.'_-----....................................................... <br /> . ............................................ ........... . <br /> y ............... ... .•---- ............................ <br /> ............... .. . ..........---- -•-._. --.•• ........................... <br /> Date ._...��!...�.-. <br /> .... <br /> .--. y� <br /> Final Ins ec"titin by: ..............: <br /> �[V' .... <br /> P •• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> C L., 1 <br /> 3;241_'!.II Dam SAA r - .. _ _._ _ r 7/72 3 M"• <br />