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FOR OFFICE USE: FOR OFFICE USE: .. -:: ..t APPLI!�t�TATI ERMIT ' l l (Complete in Triplicate) Permit -.l.o�.'��- _ ------- -----------•----..- This Permit Expires 1 Year From Date Issued Date Issued _,8' 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 LT /:A// CENSUS TRACT . ...! A --- - ----------------------------- �...... N�41L- --&Owner's Name. _/�'GpS .. .. .............. ..... Phone ................................... ,Address-----------3POoa .. ��J �Y�4C - -----City.-... .._.. .. Zip _ -------_ L ---------- ^� - . .. _.License Contractor's Name...... ....�.Aev.-T4aA!y Y— S Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------- -- \ Number of living units:.__.-]........Number of bedrooms------I Garbage Grinder............Lot Size-----.--------- ......... � Water Supply: Public System and name__ _.... ... �"� ..........._.- -....................Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Q Clay Loam (�- Hardpan ❑ Adobe (] Fill Material_ ---- ----If yes, type........................ ------- (Plot ._. .(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 permitted if public sewer is available within 200 feet,) C) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ------ ------------------------- Liquid Depth--------_----- Capacity-__ __.. -- .:_----_-_-.Capacity- ------Type-------- ------------- Material--------------- - -.:No. Compartments-----•---_------_----- Distance to nearest: Well._.............__. ._-_-------- _.......Foundation.......... . ............ Prop. Line........_................ LEACHING LINE [ ] No. of Lines --------_.........Length of each line................I........_..._Total Length _ __........._..._._......_.._.....� 'D' Box---.........Type Filter Material..._..:. ----- __.Depth Filter Material_------------_._..-------..........._.._....__......_....� Distance to nearest: Well---------------- ----.-----.Foundation.---........................Property Line........................._...__-- SEEPAGE PIT [ ] Depth------ _. -----Diameter------------------_Number-------------------------------- Rock Filled Yes ❑ No❑ Water Table Depth................. ------------- -- ---.Rock Size-- ------------ ----- ------_---..-_--- Distance to nearest: Well---.----.....-----------......_._.........Foundation---.......____. ......Prop. Line---..._.__..__..___....... REPAIR/ADDITION (Prev. Sanitation Permit#.-- _.._.......------.------------ ------.........Date_...__.--..__.__._..._...------------------) Septic Tank (Specify Requirements). -- -- --------------------------- ----------------------------------- ---------- Disposal Field (Specify Requirements)__.___... tV.S,r. -L�----_-----/ '' � .................. )'/tl� i� Tea /3e c/ --- ---------------- ._...... - -------- : . - g rQ�---....T�.. ..�.r,sT.. s ' e.�-� (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 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------. 0 AN O Owner BY------------- --- ------ -•---------=- ------------- --.....--------------------------- -•------•----- ---- ----- Title--- - -----...------------------ ----...._. ---------------------- -- (If of er than owner) FOR DEPARTM USE ONLY APPLICATION ACCEPTED BY-- - ;.�t ------_ - ---------- -DATE -- '�7 DIVISION OF LAND NUMBER.-- -- .----- -_-------•--•-------- ---........ DATE----------- ----- - - ADDITIONAL COMMENTS...............--------------------- _._ -- _._... -----------------•--- ------ --------------. ... -- --- . ... ...............................- .......- . --------- --.............................. .........-------------_------------._..... -----------------------•-----.... • - -- . �---------------------------------------- -----..._..-------- -- Final Inspection , .. .. - s - --. . EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 3M