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FOR OFFICE USE: FOR OFFICE USE: - -- --- ---------- ---------- -------�------- i APPLICATION (Complete inTriplicate) PERMIT Permit No--------- " 1 P P • ---- -----------------------------------------------' -------- r- -7 7 _ -----------------------------------------_ _______________ This Permit Expires 1 Year From Date Issues! Date Issued.._ .�_.__..._.___ V Application is hereby made to the SaniJoaquin Local Health District for a permit to construct and install the work herein described. This application is made incompliance with Count Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA Tf -y-- D - ------- ---------------------- --------------------CENSUS TRACT-/--/-------- ----- Owner's Name Phone__ fa�i- Q ------- ---- ------ ---- ---- .. ---- Address--------------------��.. - ----- - ---- ---- --City --- - Zip Contractors Name-:'---- ----- ...k . .- -_-.- - -- 501W ---------------License #- � Phone--��4_-_ { . + ^ _ p❑ House.❑ Commercial ❑ Trailer Court ❑ ' Installation will serve: � � Mdtel � Other:_._ '�• -� •' -^ - + e: � Reside nee Apartment Number of , living units_______ t______Number:of.bedrooms-•--� Garbage Grinder __- ._Lot.Size �6 _._��_�0�•` --- - Water Supply: Public System_and name,_:-�. . -- .... Lam• -- Private ` Character of soil to a depth of 3 feet: Sc! E] E]nd ❑ {Silt Clay ❑ Peat❑ Sandy Loam Clay Loam E]Hardpan ❑ �AdobeX dill Material-_____-----_If yes, type----------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: [No.'septic tank'or seepage pit perrriitted'if public sewer is available within 200 feet,[ PACKAGE TREATMENT I r I [ ] SEPTIC TANKt' ize..___ _ _-_-_- ---�-------------------------------Liquid Depth-�;- ----�------ - - Cd acit � _ ._ _ :T e Material No: Com artments_.-------��_ [ ;. .... Distance,to nearest: W*-- ----4------ --------- ---- Foundation----=- -----------------Prop. Line-- ----- ----------- LEACHING LINE., No. 6f Lines..___ ___.? _ �---�--length of,a ch line.__ ,_. r=_.._::_____.Total Length --------I_______________ Fe1 % { 'D' Box-",.-' -- +Type FiltTMre Material _ a____Depth Filter Material :_�_�___- _ -Distance,to�t� t:-WlelI -------- ---------- ---._F.oundatio�= f=0--.'#-----------Property Line-5 ------------------------ SEE-PAGE - ---------- ------ - SEEPAGE PIT ¢Q Depth �-_ Diamter.......� _ r Number _. -_ Rock Filled Yes)( No❑ Water Table_Depth s -. _ Rock Size _ l(� _.- ____: }. k -----, t -- ` Distance fo nearest: Well_'_____.'___._'.______;___._:.___..__ Foundation_-�--__-t�_"�"'--_.-Prop• Line___-._-�`_____________ REPAIR/ADDITION (PrevrS-oriitatio-mPermit`#----j.. -t------T----= Dat ------------------ ....-.- _f t E ---- Septic Tank (Specify ,Requirements} - ---=-- -- -------- r, - - -------------------------------------- -- Dis osal Field{Specify Re q•ui.rementsa_._._..: __. --------------------------------------------------------------------------------—---------------------------------------------------b-------------------------------------------}...............Y., [ • t I�fi�e) j f srWlrequired r ' 'on reverse sid hereby,certify that-1 haveprepared ap application and thatahe wokwill be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the, Sari Joaquin Local Health District. Home owner or.licensed:agents signature certifies the following: "1 certify that in the pe�orni ihce'of-the .work for which this permit is issued,it shall not employ arty person in such manner as to become subject to W.orkman's..Compensation,laws_of—Colifornia." Signed- ----- - ----= -- ------ :--_ .. , .: ---------Owner By----------- ---`- --- - --- ------- - --`--------- ------------ Title f ---'-- --.- ------------ ----=----------------- --------- -- i o leer than`owner) { FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -------'-----'--------------------:----;---- ------------ -:---DATE'._?_-A 7------------------- -- - DIVISION OF LAND NUMBER-------------- ------------ --------------------------------- -°- ------ -=--- ----DATE--.-------------------------------- I ADDITIONALCOMMENTS------------------ ----- -----------------------------------------°-----.------------------- ---- -------- --- -------- -------------------------- ------------- - . —� -- ---- `------------------------------ -�7----------------------------------`------------------------------------------------------------ ;k,T� -------------------:---------------- = � ' Final Inspection by: -- _ Date / 7.,-- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M n g. a..