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R FOR OFFICE USE: FOR OFFICE USE: APPLICATION7t, ANITATION PERMIT (Comn Triplicate} Permit No.- Date Issued_12.7._ 177 -------------------------------------------------- __.._ 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: J08 ADDRESS/LOCATI N- '�_-moi -.._ --- ---- TRACT--------------------------------- --------------- _______.__________________ ____ ----------------------------------------- - Owner's Name ---------------" ----------------------------------------- ----- --------- --------- --- --------Phone._ = -------- r r ---------- Address ------ ------------- - - - - Zip_0 � Z--------- � ' Contractor's Name--- ..____. --------License #." Installation will serve: esidence JWC Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------------------- ---------------- Number of living_units:—________Number-of-bE�drooms: _Garbage`•Grir)der------------Lot Size___-____.__.__________________________,.__.____._....._. I -----------`y-------- ---�- Water SupIly:,Public System and name--------------------- = -- ---:_----�._.--------------------------------------------------Private Character of soil to ci..depth of 3 feet: Sand ❑ Silt❑ Clay El Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpdnp❑ Adobe ❑ Fill Mated`-ial-------------If yes, type-------------------------------- (Plot ._____________________ _(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage,pjt per.�'nitted if public sewer is available within 200 feet,] PACKAGE.TREATMENT [ ] SEPTIC TANK [ ize __________________________-___________-_____________Liquid Depth._ 101 rCap c ty t'P e..C. ___---- _ aterial------------ ----- P No. Compartments arr----------------------- 67 ------ --------------- 3- � t Dis�annce to nearest: WeIL_ &0-------------------------------Foundation-/_...___---------_-----Prop. Line-------------------------- -. LEACHING LINE [ 1g No. of Lines, ________- `vR p -.r.. ,1�ng line- --`-----------------._.Total Length.__/__------_ i D' Box--/--__ Type Filter Material'T_________ ______Depth Filter Material___ ___-__.__________.____._.__.______.____.______-- �. . #� Distance to nearest: Well______________F----------.__Foundation----------------------------Property Line._._____________- _ - -------------- SEEPAGE PIT i [ ] Depth---------------- 4' .,__.Number_____________ Rock Filled Yes ❑ No I �. Water Table Depth------- - -- ----------=----------- ---------------------Rock Size------------------------------------------- "" Distance to nearest: Well _-._..__._.I---------------------------Foundation R�,�;.�...._.______-_Prop. Line_________________-._ REPAIR/ADDITION-(Prev:Sanitation Permit#-------------- ----y__--_-F-____4- .......Date ) SepticTank (specify Requirements)--------------------------- ------------------------=----------------------------- ---- ------------------ - ------------------ -- --------------- ----. � Disposal Field (Specify Requirements)---------------------- ----- --------------"------------------------- --------------------------------------------------- - ------------------ ---- (Draw existing and required addition on reverse side) E 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 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subjec�Workman's Compensation laws of California." Signed- Owner -- - -- ------- BY ------------- - ' ------Title----------------- --------- (If other than owner) FOR DEPARTMENUSE ONLY APPLICATION ACCEPTED BY---- ----------------------- -------DATE.. -71 7 DIVISION OF LAND NUMBER - ------------ = DATE ADDITIONALCOMMENTS-------------------------------------------------------------------------------------------------------------------- -- ------------------ ---------------------------- ----------------------- --------------------------------------------- ------------------------------------------------------------------------------------- ----------------------------------------------------- ---------------------------------- --- --------- - -- ------------------------------------------------ - ---------- Date-------- � ____7 Final Inspection bY------ - -- - - � - -- -- -- -- - - - ----------------------------------- - --v-- -------- --- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 ane