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FOR OFFICE USE., APPLICATION FOR SAN ITATIONI PERMIT / yM r (Complete in Triplicate) .- e a „f ermif N F :....,.. .,-• , .. .......... Issued .............5....... 7�/A. . .................................. This-PerngExpirat I.,Year From Date.lssued ,, ? Application is hereby made to the�5an Uoaquin Local Health"District :for aE_ rmit to cor► trut nd � sfall`the work herein described T1h4.gpplicotion..is m in compliance'with Count ,,Ordinan a Ido: 549 and e�kkst� I :'and Regulations: i .� rQJ :.................GENS .CR ,CT Y I JOB ADDRESS/LC ION ... I OwR � , rier's Name` : :. r. :. ?.G�. .. •..... �C-! .. ' Cortitractor's"Name ._ _ t-.• ' ...:...:.........................License # : = ( 3. Phone ' C.a .�_ ( lnstallption will serve: Residence partment House'❑ Commercial ❑Trailer Court' 0 � 'Motel ❑Other ........ ...................•-............... _ , . Number Qf living,'units:.._..r Number of droo s _.._ ...Garbag. Grinder / _� Lot Size .."_ Water 5u i Public 5 stem and name .__..._. _ . --. Priva ' Ppy. Y a ❑ Charrocter of soil to a depth of 3 feet. Sand❑ Silt Clay Peat;❑, Sandy Loam 0 Clay room 'Hardpan ❑ Adobe ill Material _W... If yes,type ...___-_.___.__. (Piot,, plan, showing size of lot, location of. system in relation to wells, buildings, etc. must be placed on re rse side.} NEW INS q'LLATION:". lNo septic tank or,seepage pit permitted if public sewer is ovoiiabie_withi.n-200_feet;1 __. �. PACKAGE TREATMENT [ ] `SEPTIC TANK f ] Size........... .............................. Liquid Depth ........ ... Capacity .................... Type .................... Material.__.. No. Corinpartmenty Distance to nearest: Well _....... ...Foundation, ...:_....!. ' Prop. Line . �. , 3 • ��s�S LEACHING LINE [ j No. of Lines _-._...1... .Length of each line.._.__.._... `......... Total Length !_:. ----- N r ''. 'D' Box ............. Type Filter Material ....................,Dep Filter MateYial_.... ... "=:...... - .. ti Distance to nearest: Well ------=----------------- Foundation ...._______.._- ........ Property Line ..- __..:_.::.,_... j SEEPAGE PIT [ j Depth ....... :''-......... Diameter ...............;--Number ............... ........ Rock Filled Yes ❑ No C3� ! Water,:TablerDepth ..............• •• ----------...................Rock Size ....... t Distance to nearest: Well ............... :.`._......_...._......_Foueldation r ....... Prop. Line . � ,•............r— -- ra... _--n i Y REPAIR/ADDITION(Prev.-Sanitation Permit�# ........... •..- .J........... .......... Date _ � ."I Septic Tank (Specify;Requirements) _.__._ ............ _-- Y-.. ..-.- ---- . . . F --• ---. :' Disposal Field (Spe6fy,,Requirements) "....._:_ —------------------------------------------- ----------------------------------------------------------- ...-..... . -•------------------------------------------------ .................................................................................. ......:..:................_..•........'...._:-..........-•----.................. ....____. 3 (Draw existing and required addition on-reverse side)' i I hereby'certify that I have prepared this applica#ion sand 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. Morrie owner or liceti-..,; sed agents signature certifies the following: , "I certify that in the performance of'the work for which this'pelit is issued, I shall not employ anr'person in such manner-, as to become subject to Workman's Compensation laws of California."- ''" 4 Signed ...--•-•-------------- - ---------------------- ......._.... Ow er � .Mt�:,w ......... i ` { By ........ - .r. .... . � (If oo ear tt an. owner) G FOR DEPARTMENT .USE,-ONLY APPLICATIONACCEPTED BY-7.1— f :.. '� `! DATE ";.._ . l ,.��y BUILDING PERMITt ISS(.)isD --- ...... ----.--......----- ........... --=---DATE- ... ............................................ -- ADDITIONAL COMMENTS -. ....... - ` ................... ............... ............................................... -----_:_•:-...., . ..............................._................._._.........s .....:..: _ :: Final Inspection by: ..: Date . A _ F SAN JOAQUIN LOCAL ALTH DISTRICT F w 13 24 1.-A;t o.,, 5M .. 7/723 ,14