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t ✓FOR OFFICE USE: FOR OFFICE USE: APPLICAANITATAPE MIT- -7x_ 707 (Complete in Triplicate) Permit o.___ i �. .`t_'t -------^l� ---- � � 4� �� Date Issued----I 2 Y ____ i This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health Districtjor.•a permit#to.construct.tandY.install the work herein described. .This application is made in compliance with County Ordinance No. 549 and exisfing Rules and Re`gulafions , _. ----------------- JOB ADDRESS/ OCATIO - CENSUS TRACT _L Owner's Name p --------------------- -- --------------- -----Phone--------------------- -------- Address s _ ------ ---- --CitY ----- ---Zip--- -------- -- - .. i_ 1 Contractor's Name `� V_ ___ ---------------License #_ _ _ � '-__ one__ _ � , I / �. Ph �. ;:� 17 Installation will serve: Residence❑ Apartment House ❑ Commercial ❑ Trailer Court,,0 ... -Motel ❑ Other ---- Number of living units:__ _____Number of bedrooms :_.��:Garbage.Grinder_ -_Lot Size _t___ __x_ ___:i------------ Water _Water Supply Public` System and name--------.--------- -- ------ ----------------------- --------- ---- ------- ------Private ❑ Character of soil to a depth of 3 feet: Sand E] -Silt❑ Clay ❑ Peat❑ Sandy Loam Q Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material_-.- --If yes, type_______ ____- ______ _ ., s (Plot plan, showing size of lot, location of system in relat onto wells, buildings, etc.must be placed on reverse side.) _j NEW INSTALLATION '(No'septic tank or seepage pit permitted if public blic sewer is available within 200'feet,) PACKAGE TREATMENT [ ]' SEPTIC TANKSize___ ----Liquid Depth-* ' .____T e_ .__Material- No:.Com Compartments Capacit� -; Type ,. -------- ,------------'-___ Foundation ---�- ----P----------------- Distance Line---------------------------- LEACHING - - - ---- vi Distance to nearest: Well -__ . --. LEACHING LINE [ ] Na. of Lines----- ------------------- Length of each line ____ g Total Length ___ __ 'DBoxy----.. _Type Filter Materia ---------------, -----Depth Filter Material----------- _ I . P Y f e 'Distance to nearest. Well_'__ Foundation___' _ Pro pert Line________ ___- __t -_. SEEPAGE PIT [ ] Depth_ __Diameter____ umber _ Rock Filled Yes ❑l+. No Water Table Depth_ --------------- . .Rock Siz ------------------------------------------------- a __ _______ ___ -- # Distanceao nearest: Wefl ___ _ Foundation : Pro Line__ -------------- REPAIR/ADDITION ________ REPAIR/ADDITION (Prev. Sanitation Permit# .. -----------------------------------.Date------------------------------------Ic 1 __----____) --------------- Septic Tank (Specify Requirements) -------------- - ---- - --------------------- ..-i.,.a.�-.�..--�•--------------------------- ------- -- --------- Disposal ------- Disposal field (Specify Requirements)--.4---- ----------[--------------------------- • -- -- --- --- - ----------------------------- ------------------------------ ------ - --------- ------------------------------------------- - --------------------------- _-- - t ----------------------------------- ----------------- 5 --- -- ---------- 1V. ,y. a ry,i+a. ,_ ! __ 1y - a-� (Draw exist`in,gjand required�additionon_reve(se_side) .; �:--- I hereby certify that I have pxepared this application,and that the work will-be done in accordance"with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District; Home owner or. licensed agents signature certifies the following. . ► w # f "I certify that!in the performdnce of.the work for which'this permit is issued, I shall not.*Mmplo-y any person in'such manner,as to become sub ject to WorkmanS Compensation laws of California.." _.. . Signed -----`Owner • �. BY - 1 Title ;. i r. _ s , .. rte. J l FOR DEPARTMENT USE ONLY`. -t , APPLICATION ACCEPTED BY' `------------------------------- ----- ---. •- = 1 - ----DATE = ] DIVISION OF LAND NUMBE -- -----------------`--------------------------------------.------------ -i ---------------------- DATE ADDITIONAL COMMENTS. --- ---------------------------------------------------------------- --- -- ----------------------- [ ------- § - - - - - --- ___. >>C -_. -._ __ -. _ _ _ _ _ ___ .. __ __ ______________ ______--_--. , -.-_ _ _ Final Inspection by: - " -:.Date_ . � EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 776 3M