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EOR OFFICE OUSE: � � FOR OFFICE USE: APPLICATION FORkS-P-41TATION PERMIT --------------------------------------------------------- i /^7/7 Permit _ --._-_(ComPletn Triplicate) i b lf� Date Issued---�. ._.___- --------------------- -------------------------------- ThisNPermit,Expires 1 Year.From�D,ate Issued Application is hereby made to the San Joaquin Local Health District fora permit to construe and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: , • .. Ii � JOB ADDRESS/LOCATION- / 7Q1---._-Z-_ ....... _.CENSUS TRACT --- - --..--------t Owner's Name------01419AIC-1.. .. -------`------------------------------------------------ Address. -------------------------- ----_Address. .5. 'e� / 011 ------- -----? ----- - -- -- `CitY i 4� ip Contractor's Name � Ni� = --- -'------ ---- --,License #------- s�'J� Phone'-------�-------------------- - 1 3 Installation will:serve: Residence ❑ Apartment House.❑ omCnercial E] °` Trailer Court+ t ... .Motel ❑ Other-- = � Number of living units:.-'./--_-_----Number.of..bedrooms- .�- ----_Garbage Grinder/, -Lot,Size--- __ .- � :__.-' Water Supply: Public System,and name l 3_-- f -- --- e ------__ --Private, -- - - f Character of soil to a depth of 3 feet: Sand 0 :Silt D_-Cetay L Peat ❑ Sandy Loam- Clay Loarn ❑ " r.. . :.. Hardpan ❑ : Adobe ❑ 1=ill 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.) ��.�` E NEW INSTALLATION: '(No septic tank'.or seepage pit permitted if public sewer is available within 200 feet,) y , PACKAGE TREATMENT [ ] SEPTIC TANK [ ` ' S,e------"-�/ -- I - ------- -----------Liquid Depth.----_--------------- - - .F t I , jj Capacity- Typeff�. .----..-Mate�ial[�Q >riek7No. Corrlpartments- '��------- :Distance to nearest: Well---------- ----------Foundation-, --_____._Prop. Line---- LEACHING LINA'" `( No sof Lines :- Lengt f each line-------7 ......... _-____Total Length._-.-- ----------------- J f f D' Box.-.1-Y.-Type Filter MaterialPfe.,C---___-.Depth Filter Material------------ ---�'-._ _____ _ ------------------------ - 0 . ( Distance to nearest: Well-: rope Line._---------------------------------- 5 =[ 1 : h -------- Dirreter =-------------=----ter --- -----' ----- R ❑ No ❑� I iWaw ---------- - - - ----------------- } ----------------- -- t : D ' :r_ '57 -- F .Pop. � -�-�-_Line P : #REPAIR/ADDITION {Prev. 5ariitataon,.Tmit~ ____ ------ -----------Date--------------`--- .- =- C r Septic Tank ( . p tfy Requir � - = "t.... -------------- ----= --- ---- - ---- isposal Fi_eld (Speci.fy_&equ-irer= ` ts) . t _� y ! p �' �` G� (Draw existing and required addition on reverse side) I herebycertify that I Ta '-e: re argil this-a lication and that the work will be done-in accordance with San-Joaquin County fY A p pp, Ordinances, State Laws'and Rules,and Regulations ofy the. San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: ; i � S "I certify that in the performrince of the work for which this permit is issued, 1 shall not employ any person in such manner as " to becon sub' t to Workman's Cgmpen ' 4'laws of California." .. , Signed � ---- JA -+Owner i r $Y------------- -------'-- ---=------=------ ------'-------------------------------------------------------Title---- 40I&107WL�------------------- ---- ------ ------------ ` (If-other-than owner) . ---- FO EPARTMENT USE ONLY. APPLICATION ACCEPTED BY t '-------------------------------------------- `---DATE. Z DIVI510N OF LAND NUMBER - - ---- DATE _ - = ' ADDITIONAL COMMENTS -----=----- -= = - > -- - ! -- ------ ------- - - - --------------------------- ------------------------- FH _ - - ------ -' -- �- � �-----------------Final•InsPection bY' - ---- ------- D --- _. :H 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M