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Z. FOR OFFICE USE: ! FOR OFFICE USE: it APPLICATION FORS NITATION PERMIT , -------------- -� ----- - - - (Complete in Triplicate) Permit No._77----- ---- �.� I __ Date Issued..,F%/7-.-r-.___..._� ......................................................... This Permit Expires 1 Year From Date Issued 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 incompliance with County Ordinance No. 549 and existing Rules and Regulations: . JOB ADDRESS/LOC ION- ...t_ } CENSUS TRACT. ------ ------ ---- Owner's Name ' 16 J. ----E-------------------- ------------------------- - ----------------------------Phone +Address-- - ------ --- -- ----------- ---- City-------------=----------------------- -------Zi --. -- ;!F' - ! "�- 7CSy Phone..--`1. ontractor sName- -- "--- --- License # 3�� Installation will serve: p ResidenceApartment House E] Commercial F-1TrailerCourt E]-M I.0 ;+Other_-------------------------------- f t ,---- Number of.living units------ --------Number of bedroomsZ___.Garbage Grinder------------Lot.Size------------ __ /_------------ __---- -__-- - Water Supply: Public System and name.___.-.._..-....:__.-._- _ _ :_ --- F ------ -- Private Y. Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ San y Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material___---------If yes, type_- ------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septicttank or seepage pit,pmitted.if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ]' SEPTIC TANK [.] ..SI e------------------------------ --------------------------Liquid Depth -------------------------- Capacity Type---------- --- ----Material-------------- ---No. Compartments ------------- ------------ ------ Distance'to ------ --- Distance'to nearest: Well------------------------------------------Foundation--------------------------Prop. Line--------------------------- LEACHING LINE [ ] No. of Lines_-_ -.----- ,-- -- -- Length of each line--------------------------------Total Length.........._----------------------------- ` t Q' Box-------- ---Type Filter Material--------------------Depth Filter Material---------------------------------------------------------------- Distance to nearest: Well--------Z%L.-- -----------Foundation-----------------------------Property Line__-_.____.-----..___.----------___. SEEPAGE PIT [ ] Depth---------------- __. _.__--Number-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth----------- ---------------------- -Rock Size --------------------------------- Distance to nearest:.:Well-------------------------------------------Foundation---------.------------- Prop. Line--------------------------- 7 REPAIR/ADDITION {Prey. Sanitation �-Permit ----------------------------------------Date-----4-- --------- ------------- Septic Tank (Specify Requirements)---.--.-- . .- _ - -- _ ------- _ ----- --- -- -- --- -------..-------------- -- Disiposal Field (Specify Requirements)--------------- -- --__ ---- 11 - r-- ! ' X- .: C� --------------- ----------- ---- ---------------- - -_------ - ------ ---------------------------- ---- F ---------------------------------------"" '----------- gk f - ---------- (Dra existin and req uired dition on reverse side)) I hereby certify that I have prepared 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: i "I certify that in the Alorniance of the work for which this permit is issued, I shall not employ any person in such manner as to becorn sub',ct orkman's Comp sation laws o California." I �JJ /� Signed----------�! - - Y¢. ----- -- ------ - ------ -------- f Title---- ) BY ---- -------- ---------------- ------ - - - --------------- (If other than ow r) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.-:--- - DATE ` ------------------ --------------- -- ---------------, DIVISION i OF LAND NUMBER.._----_------___-_ - - - =-----------------DATE-- ------------------- ----- -- -- ADDITIONAL COMMENTS--------------- ---- ---------------------------------------- -------------------- ----- ------ ------------------------- ------------------------------------ - --- ---- ------------------------C--- - ------ ---------------------- ------ I Final Inspection by:----.--- --Date--- / �� EH 13 24 SAN JOAQUIN LOA EAL H S C — 0 C �A F&5 21677 REV. 7/76 3M