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7 <br /> FOR OFFICE USE: '4 FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .......... `.`.. .3c ............. I <br /> (Complete in Triplicate) Permit I, fry-- <br /> .....................• -•------- ----_...- -- ------- 02f- <br /> Date Issued. ._.`-�`./.� I <br /> ...•••-••..................•---------- ......... This Permit Expires 1 Year from Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ,... <br /> JOB ADDRESS/LOCATION... --- ------ ------- -- .CENSUS TRACT----••-•--................. i <br /> Owner's Name. LU.S.....A~5 �0&6 --------------- .............Phone_9.8.Z Q/_.3... . � <br /> Address.............. .� . ! .rw . -- . - -- -..: --- Gi <br /> Contractor's Name.... FqRQs - --...----- -- Cit .l._.._... . <br /> +6 - <br /> .-- 5 ....... ----- - -- - --- - - -- -----License #. <br /> Installation will serve: Residence Apartment House E] Commercial E] Trailer Court ❑ <br /> Motel ❑ Other_:..' _s`---------------------------------- ---- t <br /> Number of living units:--..../._-_--'_-Number of bedrooms::-Z-_. .Garbage G6hdee-."'__.'.....Lot _ <br /> Water Supply: Public System and name-..................: ----------- ......:F'......-- . --- ---------- ------ ----•------------. ---- ------ -------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material.. .... ....If yes, type-..... -----------­............ <br /> 1 <br /> (Plot plan, showing size of lot, location of system in relation to wells,_buildings, etc, must be placed on reverse side.) ,. 4 <br /> NEW INSTALLATION: (No septic tank or seepage-pit permitted if public sewer is available withiA.200,,feet,) WQ <br /> —__Fµ `. Liquid Depth TREATMENT SEPTIC TANK Size..............r_ _ ____________-__---- <br /> - <br /> EX/ST/N(? :,Com anacitY...... TYpe.- - .. rt -----. <br /> ---- <br /> Distance to nearest: Well-------•4.............. ........ .........Foundation........ . ..._..'.__. Prop. Line....--.......-.---- <br /> LEACHING LINE ( ] No. of Lines ......................... Length of each line ..-..........................Total Length . ..-------.---------.--.......'--- . <br /> EXISTI 16, 'D' Box.... __... Type Filter Material.... -.. ....__..._...Depth,Filter Material------------------- -------------------- ---- ---- ---------- <br /> Distance,to nearest: Well............................ <br /> Foundation-------------------- Property Line.....-----------------...... <br /> ._... <br /> SEEPAGE PIT { ] Depth....-- -.... Diameter------------------- Number- ----------------------------- Rock Filled Yes ❑ No <br /> 467)(/ST/N(-? Water Table Depth-------------------------------------------------­---- ------ ------------------Rock;Size.R....----.-.- -----•- ------ <br /> Distance to nearest: Well______._.__.._._. _. t a <br /> !!// � --- ----------------Foundation_..:.._...._......... ._.Prop, Line........ �---.....-------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#..._.... .T-s......... ..._-...._.._.Qate�_ :'—, 6/-.._��I `r.__.......] <br /> Septic Tank {Specify Req uirements)...........................: .: <br /> Disposal Field (Specify Requirements). ......---T+ ._-: Q > ...LEACH.._.SNE__._E.--33.X..PfiS�E�i' b _..ptT------------------ <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 County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become sub'ect to Workman's Compensation laws of California," <br /> Signed........-- Owner <br /> -- ----------- --- ------••-------- -- -•-----...:.. <br /> By....... ----- - i(/f! _.. Title. Elf�'�a.2`D.--�....... <br /> (If other tr0-7-C.0 <br /> n owner) <br /> OR PEPARTMENT LISE ONLY <br /> APPLICATION ACCEPTED BY------------- /+". P' ` ------..DATE . --- -W7!7/77 ............... <br /> DIVISION OF LAND NUMBER :........... <br /> ...........DATE -- --- - ---- ------..... <br /> ADDITIONALCOMMENTS----------- --- - - --_....--.-----....-------- -----------------------------------------------------------------... - ----- - -- - i <br /> -------- ---- --------- ----- - ... .--- f <br /> ---------------- ------------- ........... <br /> - -- <br /> Final Inspection by: ��'�--v. -._.... -- ----------------------........................ --- ---------------------------Date. ?��.�... .-- .......... .. . <br /> `" 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Co F&s*21677 REQ, 7176 3M <br />