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FOR-OFFI6'E'USE: FOR OFFICE USE: ------------------------------ AP A ATION PERMIT ---------------- amplete in Triplicate] Permit No._ $�- l�f Date Issued...7_._ _S__20" ----------------------------- _._. 'Thi Permit Expires 1 Year From Date Issued Application is hereby mad to t Joaquin Local Health District for a permit to construct and install the work herein described. This application is made n comp once with County Ordinance No. 549 and existing Rules and Regulations: ! JOB ADDRESS/LOCATION._1'05e +�tl,/1C----------4-7i--------------- -- ------------------ = CENSUS TRACT # Owner's Name '---- ---- 14_01.f_r ------------ ---.- �:-,-:------- ----- -------------------- ------------ - - ----------- - - -.- ----,Phone-------------------"-------------- ---- Address------------'---- -------_T,9_ .-41 ------Z-7 _----------------------------' x" , _'Cit 7_4,9_4Y -------------- Zi Contractor,s`N me_#}4A_4d-'4M_6L7-C'A----- 4-------License `2_ -',_-Phone4o/i '-=F,6rr '_4r ' / Installation 'I'l,--se, a Residence LX Apartment House.❑ Commercial ❑ Trailer Court'❑ �.,-. :... I Motel ❑ Other-----"-- __. >--------------- _ Nu # tuber of living units:-.-I of bedrooms__-_--�.-3 ---______Lot Character pl -. ublic System and name------------------ ---------------------------=------------------------------ ----------------€------------------- -------- 4-Private Water Supply-. -- to a depth of 3 feet: z Sand ❑, Silt E] aCray E] ____Ift ❑ "Sandfly Loam ❑— LCla.y Loam ❑ - -k- Pea * Hardpan ❑ .. Adobe Yes, type-- -------- ------- ------- (Plot plan, showing size of lot, location of system in relation to,wells, buildings;etc.must be placed on reverse side.) W NEW INSTALLATION: -"(No"sepfic tank or seepage pit permitted if public sewer is available within 200 feet,] i r/ ` PACKAGE TREATMENT 't] SEPTIC TANK Size-_- / -0_a.____ _4_4r1--WeV _ !Liquid Depth 5 ____-___ Capacity 1�--40-0 TYPe Material-- � �= --- No`. Compartments �' ` =�-------------------- Distance -`--- --- � L: i Distance to n -_Foundation._`__.. ' e ' ; ~ -- # - t. , ..- .. .. Barest: Well..:._.__.�_O__D____,.,._-==•=--•'----- 1 -�---•------'---Pro Lme-t---�'--`�--------- LEACHING LINE . No. of Lines,_-,,-_,_ = 3-, ` _.length.of each line__------ `-'Total Length._e2 - ------- "'_____________ ! i t ? 1 Ae \D' Box._ __,7st __Type Filter Material -__-R,0 �4'.Depth Filter Material__ /= _ i______ 3 -Distant&to nearest: Well ': Foundation_ .'_ ------------,Property Line y___ +�____ _______. SEEPAGE PIT E ] Depth :_._ Diameter_ ____________5___.Number___= i Rock Filled Yes'❑ - No'E] Water. Tabfe Depth----------------------- - --------------------Rock Siz -----. ---------------------4------------------- Distance ------ --Distance to nearest; Well:. :.:_-_.-.__ ._• Foundation __ ___ .1 Prop. Lin-------------------------- __. REPAIR/ADDITION {Prey:Sanitation Permit#--------- -----: ---------- '------ -----..Date--------------------------- -1_11---- -___-) ` Septic Tank (SpecifyRequirements) r_1_ _0 ._G .�_ �r1+C = ---------- '-----=-' ---= ...' -- --------------------------------------- Disposci-I Field (Specify Requirements)___ ----------- ------------------ - - i _ a ---------------- ------------------------------------ -- ------- ---- --------------- -------------------- - -------- ------ --- - t (Drawtiexisting and required addition'on'reverse side) I hereby certify.that I-haye-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: V. "I certify that in the performance _of�'tlie .work for which this permit is issued;•1"shell-not employ any person in such manner'as to beco . subl ct i'o Workma ompensation .laws of 7C41ifornia." Signed.: ; s ._ . - _ Owner _ i BY ------- `---- - - �` ---- .------= ------ --- ---- ---- _:Title------ ------------------------------------------------- i t (If other than owner) _... .F_ . r.... '~�d�•~ *~'•FOR DEPARTMENT-ISE ONLY' APPLICATION ACCEPTED BY_.__. _ '` __DATE " I1. 1. -------- APPLICATION OF LAND NUMBER - - = ---------- ------------------------- --- ""-- -- ,,-.--.DATE ADDITIONAL COMMENTS - - - - - -- --- -- . `" � i --- ------------------- -------------------------------------- Final-ins-inspection b - _ _ - - `_ '�""r ` Date = -= '_ p Y-= = = t. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 216 Fay. 7/76 3M