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7 <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANT ERMIT <br /> --------------- - <br /> /� (Complete in Triplicate) Permit No.__7��_ _____ <br /> ------------"T -------------------------- <br /> Date Issued./f�'�-�7� <br /> ---------- <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 Ordi once No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION____(-_-_�_l--___�' ''___ r` . _------- � ' ------------CENSUS TRACT_____________.__ <br /> Owner's Name 4a A /� -- i'� (" ------------------------------------------------------------Phone--2_-3----_-� i-- <br /> 5' 3 <br /> Address - < ------- - -- ------City------ ZIP <br /> Contractor's Name - ------ ----------------------------License #--------- - ----------------Phone--------------------------------- <br /> Installation will swve: Residencef& Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---- --------------------------------- ----- <br /> Number of living units:----------------Number of bedrooms----------__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 /> Hardpan ❑ Adobe ❑ Fill Material------------lf 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ j Size--------------------------------- -------------------------Liquid Depth------------------------- . <br /> Capacity Type-- _ ____._________Material--------------------------No.' Compartments <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line:_________..._..._____--- <br /> LEACHING LINE [ J No. of Lines_--------------------------Length of each line------------------------------total Length._________'___-__- ____-.______._______ <br /> �-D'--Box_.__-------Type Filter Material--------.--_------Depth Filter Material------------------------------------------------------------- <br /> DIVance to nearest: Well---------------.------------Foundation----------------------------Property Line-----------__-__a____.______-. . <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- Rock`Filled Yes ❑ No <br /> Water Table Depth-------------------------------------------------------Rock Size-----------------------------------------------� <br /> Distance to nearest: Well-------------------------------------------Foundation------------_-------r_____.Prop. Line_____________-_.__._._____- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#________...___.._______________.___-___.-._.Date---------------------------------------------- <br /> Septic <br /> ______ _______-________Septic Tank (Specify Requirements)---------------------- -- ------------------------------------------------------------------------,-----------------�-------------------------- ------ <br /> Disposal Field (Specify Requirements)-------AAA----------- L7-6- T_6-47-------- Q-�-------- _C,+1✓�----- .1 y] <br /> ---------------------------------------------- ------------------------—----------- ---------- -----------------------------------------------------� <br /> (Draw existingand 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 N <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agent <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become s lett to Workman,'ss mpens n laws of California." <br /> Signed--- `------- ` - ----------- --------------Owner <br /> 14 <br /> By------------------------------------------------------- ----------------- ------_-----------------------Title-- ----------- ----- ------------------------------ <br /> (If other than owner) <br /> FOR DEPART T USE ONLY <br /> APPLICATION ACCEPTED BY__) - ---- -- - ---- --- -- -- -- --------- ----------------------------------DATE. - ---- �----=- <br /> DIVISION OF LAND NUMBER--- _.._ -t---------- ---- DATE------------- <br /> ADDITIONAL COMMENTS------ ��� - f - - - - <br /> --------------------------------------------- ----- --------------------------------------- ------------------------------------ <br /> c`t> ---------------------------------------------- <br /> Final Inspection by:--- - Date = '� ---- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fay 21677 REV. 7/76 3M <br />