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>v <br /> FOR OFFICE USE: <br /> APPLICATION-FOR !rANITATION PERMIT <br /> ----------- -- - <br /> (Complete in Triplicate) Permit No. __-�3-7a___. <br /> ---------=-- ----------------- ------------------------- <br /> a_'_�y.�__. <br /> _---------_----------------•---------------------------- This Permit Expires 1 Year From Date Issued Date Issued : <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein 1 <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .---77(ooe, 6vP�,,�.e-----y Co _-- -__--- <br /> d CENSUS TRACT -------------------------- <br /> Owner's NamefLSC%A_-/ /-�`�� % �!•5 -`------------------- Phone ZVZO_�------- <br /> Address -------- lo�-- -G.L��ZOV26 . ------------------------------------- City <br /> Contractor's NamerG '_------------License # --- Phone ---- � , <br /> Installation will serve: Residence ❑Apartment House-E] CommercialTrailer Court i❑ <br /> Motel ❑Other -------------------------------------------- // <br /> Number of living,units_____________ Number of bedrooms�,� __Garbage Grinder ------------ Lot Size __-!A0_- <br /> Water Supply: Public System and name --`---=---------------------------------- ------------------------------------------------------------•---------PrivateX <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 /> (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 seepage pit permitted if public sewer is available within 200-feet,) 10 <br /> PACKAGE TREATMENT f ] -SEPTIC TANK![,] Size__ ___ ________________________________ Liquid Depth ____.:57.-____________ <br /> Capacity /_ Q_4.__.__,T e _ fir`-'- Material__ _ No. Compartments r { <br /> 1 p Y YP <br /> Distance to nearest: Well ��_S______________________Foundation ___ACJ__-________ Prop. Line ------ <br /> - <br /> -•--- <br /> rr ------ <br /> LEACHING LINE [ ] No, of Lines _______f______________ Length of each line___IV-_______________ Total Length ---Id--------------- <br /> .De <br /> j <br /> 'D' Box Type Filter Material p <br /> � �-�__ __ th Filter Material _-____;�__ - <br /> Distance to nearest: Well ---/Q�---------- Foundation ---------- Property Line ----- -__________ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth --------------------------------------- --------Rock Size ---------------------------- - <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop: Line __________.._.......__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ----- <br /> Disposal Field (Specify Requirements) ----------- -------------------------------------------------------------- ----------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------ ---- ------------------------------------------------ --------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that f 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 Joa4uin Local-Health District. Home owner or Iicert- i <br /> sed agents 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 <br /> as to beco s ject o Workman's Compensation laws of California." <br /> Signed ---- ---- ------ --- - ---4Z ------------ Owner <br /> BY ------------------------------- --- --- ------ice-•---- Title --- ------------------------------ <br /> (If'.other an er) <br /> j <br /> FOR DEP ENT USE ONLY �✓ <br /> APPLICATION ACCEPTED BY ---- ------------------------------------ - DATE -----Z =/173' <br /> ----7 I <br /> BUILDINGPERMIT ISSUED -------- --------------- -------------------------------=--------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------ ----- ----------------------`------------------------------------------------------------------ --------- <br /> ----------------------------------------------------------------------------------------------------- ------------------------------------------------ ---------------------------------------- <br /> ------ ---------------------------------------------------------------------------- ------------------------------------------------------- <br /> ---------------------- <br /> --------------- ----------------------------------- - ---- ------------------------------------------------- <br /> -- - ----------- -- - <br /> - -- --- ---- <br /> ---- - -- ------- <br /> Final Inspection by: -------------- ---- --- ------ -- ---------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E_ H- 9 1-'68 Rev_ SM + <br />