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f n� FOR OFFICE USE: `°"'* ' FOR OFFICE 17SE- : APPLICATION FOBZ ATION PERMIT f ------------------ ------ = Permit No-------77_��b [Complete in Triplicate) I "1. % 1 i - � �`- Date Issued___..'_-.- -- ------------ _.-.__..-_.__ This Permit Expires 1 Year From'c nte'Issued Applicationishereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance ithcp unty Ordinance No. 549 and existing R es and Regulation ;------ ---- a r l is S ��NSU9,TRACT 1 ------- ---------- ------------- -41 ------ ---- JOB ADDRESS/LOCATION-.__--- __ � ---- I -------------------------------------- 7r, � Owner's Name- ------/6 d� � Phone t Address---- ---- =---------' ----- - City Zip ------------------------------PF f = License*,Name ------- --- Phone_-- _ installation will serve: -' Residence-❑ Apartment House ❑ Commercial e ' Trailer Court ❑ Motel Other-- '-------------=----------- -------------- 4 ,,Number ofdliving units:------_----.---Number of bedrooms..-_- --- Garbage Grinder___.-Y-.....Lot Size.--. . - ;.___________________ `'Water Supply-Public System and name...--- --- - ------ -- �. " - ----------------- -------------------Private 01 - )v- haracter of soil to a depth of 3 feet: Sand ❑ Silt. Clay ❑ Peat ❑ Sandy Loam ❑= Clay Loam " �'�" t - —Hard-pan ❑} Adobe�Y ;Fill Material-- -_-.Jf yes, type•------------------------------- " S 3 L(Plot plan, showing size of.4ot, location of syste in relation to wells, bu±d'i-ngs,etc. must be placed onsreverse�side.f 1 NEW INSTALLATIQN :[No"se,pti.c.tank„or_se.epage pit permitted if public sewer is available within 200 feet, �/ PACKAGE'fREgTMENT,, [ 1. SEPTIC TAMC y'[:]r”- Size-- -- -- _-- --------Liquid Depth � • Z. -4 - { } Ca iaCity -.704 -Q i-- --Type-gip ------ -- --Material No. Compartments 1 r _ )4{ance to nearest: Well :.�+ ,1�.�---------`--Foundation--.-AOProp. . tine /Q �. . ; Total, Len gth.-_� ____-LEACHING-LINE No. of'Lines ----.-----:Length of each line.- � __- -_------------- j'D' Bo� TY'e Filer Material-----I- 1.--Depth Filter Material-_-f: ----------------------------------- --- ------- Distance to nearest: Well-:_-t/ __�-.-_-d _ --Foundation.-. _ `:, , _.-Property Line--�.--_- SEEP,4GE PIT! [ Depth-- - _--_Dameer.- 6�� i�-Number_----. Rock Filled Yes No ❑ P ------ ------ ----------------------------- Water =able De �h- ---• t � � - Rock Size `' �------- -- ----------~---- -. �` Distance to nearest; Well _ ----.--Foundation.,/-�lz.---------- Prop, Line---- _____________ REPAIR/ADDITION (Prev. Sanitation Permit#------------' - -:---- -------- -----------Date-----------------------------------------------) Septic Tank (SpeciFy Requirements)----'------- ------- -------------- i Disposal Field (Specify Requirements)----4-- � � �f�`� - ---[' *. - ... ------------------------ -------------- ---------=---------' --------.�------- --------_-- - ------------------------------- .. ----------------- -------- ---------- - It - _ I _ 7 - i (Draw existing and required addition on reverse side) , I hereby certify that l have prepared ihisl application and that the work will be done in accordance with San Joaquin County Ordinances,i State Laws, and Rules:and Regulations of,the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: t ,g ify that in the performance oUthe work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of`California." '.,.� I } Signed " ''------- ----i-------- ----- ----0 neer f 4 By- - -- - !� .-�/ = ' Title I t Of other than owner) Y , I } i FOR DEPARTMENT. USE ONLY APPLICATION ACCEPTED'BY= {- -- - = ---------------- ---- ------------------- DATE. - 1.. DIVISION OF LAND NUMBER ------------------------ DATE. ADDITIONAL COMMENTS ---------------------------------- ----------------------- --- ------------------ ---- - -- ---------------------------------------- ----------------------- 711 ---------------------- -------------------------------` --------------- - ------� �--3�t?---- ` F' We � ------------------------------------ - --- -- Final Inspection b :� , � 7--. c -'D-K.---- � --------- - ------Date- -------------------- --------------------- ----- P y TF EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M a At