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FOR OFFICE USE: FOR OFFICE' USE: -- -------- -=:: ------- APPLICATION (Complete SANITATION Triplicate)IAicaOe PERMIT 9f 4 ,, Permit.N 9 -4------ _0------- -�!-. ._.__ —�` This Permit Ex ires 1 Year From Date Issued i .4.�� Date IssuedS_ ___-_ __ Application is hereby 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 with County Ordinance No. 549 and existing Rules and Regulations { JOB ADDRESS/LOCATION ------/04; ---------' ------ ------- -- ---- ---- -------CENSU5 TRACT ---------------------------------- Owner's ---- -------- =---- --Owner's Name _.. . = - � - ---------- --- . . Address---- - ------- ----------- ----------- . ------ ------ City-- Zip---- :'- . T I Contractor's Name- ------ = -- ----------- ------- License _#Zs 3------Phone-.-`--------- k Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ o I a Motel-F]---rGther .., - G. I I Number of living units.-___.. .-._.-..Number of bed rooms _7 .._ Garbage Gr.inder.----------_Lot Size..--------- _ _r --------------- Water Supply: Public System_and name........--------- -- --------------- ; 1 ---------- ---- ---------------- = -Private E] Character of soil to a depth of 3 feet: : Sand ❑ 'Silt❑ Clay ❑r Peat ❑ Sandy Loam ❑ Clay Loam ❑ �! --.._ -- --- -------- ' � Hardpan ❑ ? Adobe� Fill Materir�l__� __..lf:,yes, type................. � I! !I (Plot plan, showing size of lot, location of system in relation to welk�,bitild'ings, etc.must be placed on reverse side.) NEW INSTALLATION:' (No-,'septic tank-;or seepage ,pit permitted if public sewer is available within 260 feet,)PACKAGE CJ -TREATMENT SEPTIC TANK [i] 4Ze. - - -- ----- q D�Pfih{ i ------------- Capacity----.--' ---------- Ca aciY ' -----.T e--- Mari l--- No. C ._ _._,______________________Yp ��'--> _ � Distance�to nearest: Well--------- _ -------------------------- oundation-------.---- - Prop. � Line.-- ----------------------. LEACHING LINE. [ ] No. 'of Lines----------------------------Length of each line - ----.__-.. --------------Total Length---------.-------- - _-------- D' Box-------------T a Filter Material_____________-➢_-...D De -F+Iter Material----- Proper - - -- ----------- ----------- ------ Yp eP - DistancE<fio nearest: WeIL_.___ ____. Foundation- --. ty�Line_.__ E__. SEEPAGE PIT [ ] D ----------- -...f`-'i_ .._..._---- Rock Filled Yes ❑ No❑ [ Water Table Depth-------------------------------------------------------.Rock Size--------------------- fr Foundation - Trop. Line._.. REPAFR ADDITION Prev.Distarice.to nearestWel1.-:--1-- -------- -- ------------• --------.Date--- -- -------------- Septic - ------------- -'-------- ----------------------- REPAIR/ADDITION --------- --- -�---� / [ Sanitation Permit#- -__:-{------------- i ) I I Septic Tank (Specify Requirements)----- __.-.'________ _ _ ____ ---------------- '" { Disposal Field (Specify Requirements):........-.. `_.__.r ----_ -- --------- ___ b K��---- -------------------------- ----------- ----=--------------- ---- . i 7 (Draw ezisting'and required addition on reverse side) " I hereby certify that I have prepared this p'pli atio4r and that the work will be done in -gccordance w ith San 'Joaquin County Ordinarices, State Laws, and Rules_ and. Regulations of the San Joaquin Local Health District:. Home owner or licensed agents signature certifies the following: "1 certify than in the performance'of the work' for". which this permit is issued, ,I shall not ploy any person iri such manner as to become subject, to Workman's Compensation l laws of California." ! �- Signed-- - --------- -----`-- ---=-----'---- =� ----- ------- :-- -- '-�---------- ---;Owner By- - Title - . -- ---------- - ] i ther than owri_erl ' r FOR DEPART NT USE ONLY APPLICATION ACCEPTED BY = -----------------------------DATh- u � ADDITIONAL COMMENTS---- �OY1/ - j:��t i�lh{ CO.AA ------5 ),a-..��..__.a15 ---•--- DIVISION OF LAND NUMBER._-- - -- _ +----------------- ------ --- ------------- IL ---------------- ------------------==----------- -------I_S - _.�. + a----.------------- - = - -------------------- -- --------------------------------------------- - -- �1 A i� s ✓ f X.`x R1_ _; vim l II s4j L •----_••- - ........__ ---. Final Ins spec - �. . . . _ - J p y:.. -- - -- 9- (>�r--- ---------J----------- ----------- --------------- --------Date--- / ----- -------- --- ---- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.-7/76 3M