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OFFICE USE: Z FOR OFFICE USE: APPLICATION FOR STATION PERMIT -------•-- --------------------------------------- ' Permit No._?7— 7l d 771 (Complete in Triplicate) ---- Date Issued- -__ _-'77 --------------------------------------------.---.___.__ This Permit Expires 1 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 Q This application is made in rcomp/lliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LO TION L !----- --------- - -----------CENSUS TRACT----- - -------- ' - Owner's Name- - Address ------------------ ---- ------------------------------------------city------------------------------------------_-Zip----------------- //�� Contractor's Name--L'�/r - ----------•------ ------------------------License # ® e�-----Phone,!M - Installation will serve: R sidence (�.�-Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------------------- (� Number of living units:;._-.-__.___Number of bedrooms_---/---_-Garbage Grinder-___-___--;Lot Size-------------------------------------------------------- Water Supply: Public Syste$n and name---------------------------------------------------------------------- ------------------ --------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sander Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe❑ Fill Material-..------- yes, type----i---------�-__----__-_-- (Plot plan, showing sizE! of lot, location of system in relation to wells, buildings, etc. alit be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer iso cNai)able within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANKSize [ ] ---------------------------------Liquid Depth------------------------ Capacity/ �ype__& Material---------------:----- No. Compartments----IL•-------------------- Distance to nearest: Well-__----_-______.__ -. P., Q---------------Prop. Line---S____-____-_--__ - ----------------=--`Foundati" n --- --- LEAQ3 ING LINE ( ] No' of Lines-----------------------------Lengjj each line,.,--.------ ____-_._-____Total Length--------------------------------------- 10 __ _-----__ _--_____ -__ . ___-- 'D' Box � T e Filter Material De l--. �________. ____. __ ______-_-_. .. fe-- ---- r YP ptter Materia! '}Distance to;n"ares? Well--- ------------------------Found #on---- -:-- -----------------Property Line ---_----- -----.------------------ SEEPAGE --- --- ----_.SEEPAGE PIT [ ] Depth------ ------F "` .�_ ?_ # �..�_-: Rock Filled Yes ❑ No❑ Water Tpble Depth__ - - ".-.' . - > :I-----------Rock�Size------------------------------------------------ Distance ------- -------- -------- -------------- Distance to nearest: Well---------------------------------------------Foundation--------------------------Prop. Line------------______________. REPAIR/ADDITION (Prev. Sanitation Permit#._.__------___�_�, '_ Septic Tank (Specify Requirements)-_--____ Disposal Field (Specify Requirements)-_�,�/( -?�-eP_�T'�_�" '' -------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ (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 Coun Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agen 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 to become-subiject toWorkman's Compensation laws of California." Signed- 1 --------------- ------------ ------ - ------------Owner BY------ -------------------------------------------------------------------------- -----------------------Title--------- --------------------- ------------ (If other than owner) OR DE RTMENT SE ONLY APPLICATION ACCEPTED BY---- DATE. �� DIVISION OF LAND NUMBER. ----------- --- ------------------------ - -------------------------------------------------- ------------------------------ --------- DATE ADDITIONAL COMMENTS--------------- ------ -- 74 -----------------------------------------------------------------------�-------------- ------ --------- ------- - --- - ,' % - � - ------- --- ---- - - - ---------------- Final Inspection by a 1�� -- -G � -�-' - - - Date .�`� -�- - - - EH 13 24 `'" "�SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M