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FOR OFFICE USE: FOR OFFICE USE: <br /> WAT //------•------ --------------- ---------- -------------- APPLICATION FOPermit No✓�7�—AVICo . et <br /> i Date Issued. _ /-�.7 -� <br /> ••--•--•-- f/ ---- ------------ <br /> j ares 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 o. 549 and existing Rules and Regulations: <br /> - CENSUS TRACT............... .. . ....:... -- <br /> JOB ADDRESS/LOCATIO ....... .. '.. ...7-_...... <br /> a f , <br /> Owner's Name. .. -- Phone.... ----•--------- <br /> . .. ...............City .- ------ zip------- -------- ------------ <br /> Address9 <br /> Contractor's Name { . . .... ...-- . •. ---.License -Phone- ------• <br /> Installation will serve: Residence P;Oo'Apartment House ❑ Commercial ❑ Trailer Court ❑ _ <br /> Motel ❑ Other-... -------------------------- <br /> Number of living units:.......1.......Number of bedrooms....:--.Garbage Grinder.....-------Lot Size..:.- ......... ............ .. <br /> Water Supply: Public System and name---------------- -- ------------------- ....----- ,...... ----- ----=...----.Private' <br /> y F ❑ ❑ yE] ❑ Y ❑ y Loom El <br /> Character of soil to a depth of 3 feet: Sand Silt Clay -Peat Sand Loam Cla L <br /> Hardpan ❑ Adobe PV 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,) J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.........................------ i Liquid Depth-_- .-.------------ --- `, <br /> qM <br /> Capacity -- ---- -- ------Type---...------- .-.Material--------------............No. Compartments-----.:-:....----:----... - ..... <br /> Distance to nearest: Well-=------- ------Foundation............ ...... t.....Prop. Line_..--------- -- <br /> CQ <br /> i <br /> LEACHING LINE [ ] No. of Lines----------------------------.Length of each line ----------------------------.Total Length ...----.. ----------- ........-- I <br /> i .. ... .D' Box . ..."""Ty`pe'Filter Material --":Depth Filter Material.....--~- --'---- ------- 1 <br /> Distance to nearest: Well----------------_......-.-.Foundation.....--•-------------_----Property Line_' ................. <br /> SEEPAGE PIT [ j Depth... - Diameter....................Number-.- ......... � "'..:. "-•--,-�-►�-- Rock Filled Yes E] No❑ <br /> WaterTable 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)........ D - ----- r t.... <br /> ........ ......... <br /> i <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 /> l <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 subject to W km s ensati laws of California." <br /> Signed- Owner <br /> BY----- ......... <br /> • 3 ............ ........ ......Title....- ------------- ....... ............ --------- ..--- <br /> (lf other than owner) <br /> x� <br /> S <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- ------..DATE. kJ'°�1-1 ......... <br /> DIVISION OF LAND NUMBER..---- ...... DATE.-----_-------�... ............ ---- <br /> ADDITIONAL COMMENTS----------------- -------- --------------------------------------- <br /> --------------------- <br /> -----......---------------..._..------ <br /> ---•-------- ------------------- - ------------ .....--........----------------•------------- -----------..... <br /> -------•------••--------• ­ ----------- -------- ---------------- <br /> Final Inspection by:. .... Date... .a\--?--------_--------.... <br /> Eli 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/76 3M <br /> t' <br />