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o d� FOR OFFICE USE: h' r FOR OFFICE USE: APPLICATION F'�R'a�NIT`ATION".PERMITrcl --------------------------------------------------------- r- r 7d / (Complete in Triplicate) Permit No.7_._.'_ ---------- �/1 Date Issued_ ----------------------------------__..___._---____-_. _. This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District fora 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. ---------- --- ------- L --------- ----------------------------------CENSUS TRACT --------------------- Owner's Name ----- ---- ------- --------------------------- ---------- -------------Phone_ -- ----- Address----- -------- _- -----------------City -- Zip Contractor's Name ------ ---------- ------ --- .--�8"7�-- --------------------License #----- `f~,j" _ Phone---Y44---W-7------- Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Cb rt ❑ otel ❑ Other - --------------------- ---- -------- -�� -�`. � Number of living units;-----I_---___Number of bedrooms-_-.-j_---Garbage Grinde,r___..__.:__=:Lot Size /41_-_. CT ------------------ -__--- Water Supply: Public System and name ------- -----------------------------------f----------------------- ----------------------Private Character of soil to a depth of 3 feet: Sand D Silt C]i Clay ❑ ' Peat❑ Sandy,.Loam ❑ Clay Loam%-0 Hardpan ❑ Adobe [g[ Fill.Material------------If yes, type_.-f___----___----------------- ,(Plot _________ __,(Plot plan, showing size of lot, location of.system in relation to wells, buildings,Fetc. must be placed on reverse side.) NEW INSTALLATION: (No septic-'tank or seepq-ge pit. permitted if public sewer is available within 200 feet,) ! R PACKAGE TREATMENT ,h '• `'" j _ j-] SEPTIC TANK Size------, ------Liquid Depth.- ---------------- Type _______ _i Material_ No. Cam artme Capacity1 yp p nts. Distance to nearest: Well__.___ _:__ .. _. Foundation,___--_lO_____________Prop. Li ne27`.__-.__ µ LEACHING LINE j�] No. of Lines.__.____ °_w�_T� •Len th of each line------P�'._ - Tofal"Leri tfa�___�_7>r1_ ________________-___ t _ ..g ; g D' Box. .__ __ Type Filter Mater'JY _____Depth Filter Material-------`8--------- -------------------�__--________- Distanceto nearest: Wealf ? l_f�............... _ Foundation_____h�___f_�w„__ Property Line._-.- _ _________________-._- SEEPAGE PIT Depth___Z�----- Diameter_�_,1___- _Number_____________ _____________ Rock Filled Yes j Water Table Depth- - Rock Size -- J = ------ r Distance to nearest: Well--------`-Sd----------------------------Foundation.----f0 Y---------- Prop, Line-----7- __.______._ i F REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date-- ---- ---- ------------ -------------- Septic Tank (Specify Require ments)_---:__._-_-__._ � .. f .. i + �i b i Disposal Field (Specify Requirements) - - --------------------------- --------- --- ------------------------=----------------- ---------------------------------- i ----------- ---------------------------------------------- --------------------- --- ------------ -------------------------------------------------------- -----------------------------------: ---------- ----------- (Draw existing and required addition on reverse side) ¢ I hereby 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 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 subject to Workman's 'Compensation laws of California.” Signed------------------ --- `: --------------- ----- ------------- ---Owner 7. BY ��'�/ ' i _ .'Title.- ---- r - (l other than owner - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- DATE.------- i 7 DIVISION OF LAND NUMBER____ 1 } t: . -- --- DATE ------------- -- ---------------- ADDITIONAL COMMENTS-----p�--- Ck----- __ -- _ -w ---------------------------------------- - ------------------ ------------ ---------------------�O-Z�_2 -------- 4 ------------------- --------------------------- Z w ---------------------------------------- --------------- --------------------------- ----------------------------------------- --------------------- ---------- Final Inspection by--- ----------- Date '149 ur-77 EK 13 24 SAN JOAQUi CAL HErAL H DISTRICT F&5 21677 REV. 7/76 3M A