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FOR OFFICE USF: FOR OFFICE USE: - �4PPLICAOFOR SAN ITATION PERMIT0 - ti ,' ---------------------------------------------------- - . 9- (Complete '' riplicatel Permit No.� _-wZ_ Date Issued3_-XV)l -------------------------_____.-------------------.------ This Permit Expires I 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: JOB ADDRESS/LOCATION.-..1_/ 47I-- - _ - - --------..CANS 7- - - - - : ---------- ----------- -------.. Owner's Name.------------- `ice`--- ---- --- --- --- -t --- - ----- Phone-------- Address 1-7--------�7------ --- --------- ••------- ------------- City ----------------------------- -Zip �'� Contractor's Name---____-. - '. - .--------License #--- Ar Phone---------------------------------- Installation ------------------ --- - - - ----- - - ---- ---- -- Installation will serve: Residence Apartment House ❑ Commerciai ❑ Trailer Court.❑ Motel -F Other ------- -------------- Number of living units:-- �- _------ Number of bedrooms___•�_-Garbage Grinder----_ .- __Lot:•Size-- ----.-_ Water Supply: Public System :and name- -:-.--------- f ---------------------------- ---- - Private'. Chpr_acter_of_soil to a depth of 3 feet: ` .Sand Silt❑ .Clay ❑ Peat.E],. Sandy Loam_ Clay Loam t-lardpan ❑ Adobe!Q Fill`AAerial------------lf yes, type------------------------ ------- (Pl6t --------------- - - --(Plot plan, showing size of lot, location'of system in relation to wells, buildings etc_must be placed on reverse side.) e a NEW INSTALLATION: (No septic tank or seepage pit permitted ifk�-ubl.ic sewer is available within 200'feet,} PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size- PACKAGE -------------- ------ -------Liquid Depth---------------------------- N :-------- ------------- .� Capacity. Type- ----------------- Material -----` ---No: Compartments -------- - Distance,to nearest: Well-, ------Foundation_::___:._'-:- '------ -Prop. Line.------------------------ LEACHING ------ •--LEACHING LINE [,.]. No. of Lines---------------------------------__:_--.Length of each bins _.----- ------------ Total Length---------------------------------------- 'D' _ __--------_--_- --------------- ;-- 'D' Box-- .--.=.-Type Filter Material:- _'_°__..3_'= __Depth Filter Material------------------------ Distance�#o nearest: ilVell___ -----------------------Foundation-- ---___ ------____.Property Line __. ----- - -- T��-._---Dep-fh _--------Diameter-:------ ___ fiber--- ------ ------ ------ Roc;VFifed Yes_.❑ No3�- Water Table=Depth-----------------=--- -------------------------------- -.Rock Size----- ------ Foundation---------•--------- -- Prop. Line--' Distance;to nearest:1Nel ----------------------------------------------- ------------------------- REPAIR/ADDITION (Prev.(Prev. Sanitation Permit#------------------------------ -------------------:Date.----------------------------_----_-'_---------) Septic Tank (Specify Requirements) = _---- -- .�------------------ ----------- __ = ----- ----------- ----- =osaeld( ecify Requirements} --- ----------- -- r---- r : o ° (Daw existing and required addition`on reverse side) I h reby certify thati 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 performance of'the work for which this permit is issued, I shall not employ tiny person in such manner�as to become.subject.to Workman;s Compensation..laws of California." Signed - --- ------ -- - Owner - =- BY------•- = Titl ------ -------- ---- ---------- (If other than owner) ; FOR'DEPARTMENT USE ONLY APPLICATION ACCEPTED: BY- - - __ _X`------------=---- --- 1 z--- - - ----------- --------------------- --- ---- -- ------ -----DATE -� - � - - - OF LAND NUMBER:----------- ---------------= -----DATE------- ------------------------------------ DIVISION ' ADDITICINAL COMMENTS- - - ---------------------------------------------------------------------------------------------- -- - ----- --------------- ----------------- --------------- ----- ---- -------------Final Inspection by:----- - - ------- .4 EH 13 24 SAN JOAdUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M