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FOR OFFICE USE: APPLI ITATION PERMIT FOR OFFICE USE: {Cam ete in Triplicate) Permit No.-. / . 1017 is Permit Expires 1 Year From Date Issued Hate Issued_" _�'�� Application is herebymade to::fhn Joaquin Local Health`Di.str for a permit to construct and�insfa.11 t This application is made in compliance with County Ordinarf& No.)64 grid"ex-isting=Rules and Regulations: work herein described. JOB ADDRESS/LOCATION,-e/ r Owner's Name. _-- ---- AltSUS TRACT ---------- -------" ----_ _ ------- F Address --- I-7- [ -------------------- ------ ------- , I l City- --- ZiPContractor's Name----- --------- - License #---- ------------- --Phone------------ Installation will serve: Residence ' _ ------ ❑ Apartme t House.❑ �Corrimercial ❑ Trailer Court ❑ r •.. ; ; Motel ❑ Other- ' -----�----'--- ----- -----=' : Number of living units:------ --------Number!of bedrooms_ ""- _-"-_-Garbage Grinder" "-_,-,__Lot Size.-_"-__- I Water Supply: Public System and.name-:�- _ "" --- .-. - - --- --------- --------------- ---------------Private E] Character of soil to a depth of 3 feet: Sand [❑ Silt❑ Clay ❑ : Peat❑ Sandy Loam Clay Loam ❑ :Hardpan❑ Adobe ❑ Fill Material". ---------If es , Y tYPe----------- = - -- --- � V (Plot plan, showing size of lot, location of systarri'in,�elafiori'to wellsi buildings,;etc..must be placed on reverse side.] NEW INSTALLATION: } `. ' -jNo septic tank.or 'see a e' it ` ' P g p" permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANKfi- [��) - - E Size..-'---- --, x Ki-.. ------------------Liquid Depth Capacity'b/ f /t �Q ---�'---------- t C9 Type ==y - _Material � (� f? 1' - --_ }�`�?'- No. Compartments"___-- 'v? � 4P --'U�lDistance"to nearest. Well -Fo�ndatian. [ ] -i -------------=__.Prop. L'ne2------------------------ No:--of Lines-� eachline.®- ._ t To al.• Length fib------------ E ''D' Boz_`_' !Type Filter Material-.,-_ _---__-__'"-__Depth Filter Material__' -" -- Distance°to-ne�rrest: Well = Foundation ----- - ---- SEEPAGE PIT .. ;- ti . . .. .. - e ------- ----- - .. [ l Depth - ---.Number ? -. roper y �n Diameter Rock Fill j ,�'... -- ---- er1 Y ]orf Wate`u� Tablev-DDepth.--; __ '-C r� �5 :----- -- == r. oc .z F7 �, R k S' e. 0 D.i`stance�to nedre�f: 1rVell- '"-. ' ,. - .....� ------ ------ ------- -- ' �� ! oundation"_"---- ---._.Prop. Line ----- REPAIR/ADDITION Prev.-Sanitation Permit#: Se tic Tank (Specify Requi , r = =-= -_ ----_-_---------------- ------- ate -�- ------- 1 -- ----- rements) = _ --- "------- - -- --- --- ---- " -__""-------"Disposa Field (Specify Requirements).- -..1------' ----------- ------------------------------- ----------=---- " ------------------- -- - - --- -- ------------ ---- --- --------- ----- - __ - - {- raw exusting - -- - ----- -!•addition on reverse --- ----- --------- -- everse side) I hereby certify that I have prepared.this application nd th�t'the work will be done in accordance with San Joaquin-County f Ordinances, State Laws, and Rules and Regul ns o he San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: "I certify that in theperform - l ance 'of.the:work for. whit this permit is issued, I shall not employ any person in such manner as to become subject to:Workman's Compensation- laws of .California.'-' Signed- __ By- j ( - --------- E----------------- ---------------------------------- It l ofher than.owner] F DEPARTMENT USE'ONLY` , APPLICATION ACCEPTED. BY.: --___ �� _. . . - . OF LAND NUMBER ------- - ------------- DIVISION -DATE ---- -�- - --------- :.: ------DATE"-_.- " ADDITIONAL COMMENTS--- - :: s-" ------------ ---------- - --------------------------- -- --- - ------ - - • --- -------------------- ------ --- --- ------ ---------------- ------------- t ---------------------------- ------- ------------ -------------------------------------------------------------- Final-lns Inspection b P Y- - Date 13 24 ------ ---` -------- --- • SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M