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FOR OFFICE USE: fj -� F" APPLICATION FOR SAN TA4 IS I�i � "I FOR OFFICE USE: } ' -------- -- L � f (Complete in 'cate] fJ Permit No..7_�- _--- -;------•-•--------------- --•--------- �1 li;_ f, � 1�1� 1 --- ------ This Permit Expires 1 Year From Date Issued Date Issued_. : f _1�,1�'�:t3' iii` Application is hereby made to the San Joaquin Local Health District for } " q � m1-tojgQr{s�trr, 6.install the work herein described. is application is made in compliance with County Ordinance No. 549 and existing 1�ules anLE Regulations: t " .3 JOB ADDRESS/LOCATION. ---------------------------------------------------CENSUS TRACT ner's Name---- � -- ----------------------.Phone-------- ddress--- ----- City -- cz--Zip------------------------------ Contractor's Name--- --- --- --- 'G- ..--------- ---------License #_._.3�f,_2___zA�'Phone ystallation will serve: Residence Apartment House.[] Commercial ❑ Trailer Court ❑ r Motel ❑ Other living units------ of bedrooms Grinder____________Lot Size E__ 6 J umber o _ Nater Supply: Public System and name______________ Private [R - --------------•----------------------------- - ---------- - Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ C Hardpan ❑ Adobe [� Fill Material------------If yes,type______________________ `Plot plan, showing size of lot, location of system in relation y to wells, buildings, etc, must be placed on reverse side.} EW INSTALLATION; (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] ?ACKAGE TREATMENT SEPTIC TANK [dr Size'-VIA-f' « x_.✓r //_______Liquid Depth.__ __________ Capacity__- TA-Q_------•Type- Material-- -- ---------No. Compartments-----3------------------------- Distance to nearest: Wel L___..._3v -------------- Foundation ____Prop. .Line_ ��"-_ FtEACHING, UNE No. of Lines____--3------------------Length of- each ling _---�:G.: _`____ .Total Length ___ ---_____ �� D' Box------ ----Type Filter Material______ ___Depth Filter Material_____ _ ____________-____________.-------------- _------ Fill __.__ Distance to nearest: Well__._�_.�!t7_ --------Fouridation__.__�_Q_ `"_______.Property Line___ _ _________________ II( } SEEPAGE PIT j Depth_,;:2-�_ Diameter____- __ Number-------------___3--------_______ Rock Filled. Yes f No. Water Table Depth s Rock Size-- 4 _o"� --'� Distance to nearest: Well------ 1 _______________Foundation____le�_------Prop, Line----7�� REPAIR/ADDITION (Prev. Sanitation Permit#--------------•----------------=--.------------ Date-------------------------------------------- -1 [ieptic Tank (Specify Requirements)---------------------------- ------------------------------------------------------------------------------------------- IDisposcil =------------------------------------------------------------------------------------- --Disposal Field (Specify Requirements)------------------ ---z -----•-------------=-•---------------•------------------------------•------------- l ----- -------------------------------- ---- . :------------------------------------------------------------------------------------------------------------------------------- (Draw existing and.required addition 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 Qrdinances, State Laws, and Rules and Regulationst 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 o become subject to Workman's Compensation laws of California." Signed. : ---------- ---------------Owner fBF = ----------------Title- -C------------------------•------------------ ------ Y (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION � -. r� ON ACCEPTED BY. - -•-�- -----------------------------------------------DATE---7--__,2 -_'r DIV ION ADDITIONAL COMMENTS LAND NUMBER. = -------- - -------------------------------DATE-------------------=---------------------------- AL COMMENTS------------ f RZ ---------------------------------------------------------- ----------------Fr;-------------------71------------------------------------- ------------------- - - ------------------------------------------ - - incl Inspection by: -------------------------------:---Date---------- - ---a --- / _.l -- ---- :H 13 24 - SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677REV.7176: