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FOR OFFICE USE: ' r FOR OFFICE USE: - ( g n�r O�/ � (� _ � APPLICATION FOR nA7riplica0e PERMIT �1 .�: ` � �.�` Y ----- -------- - :PArmlt No.. This Permit Expires 1 Year From Date Issued Date Issued.3� �7� Application s hereby e to t e Sa oaquin Locaf ealth istrict fora permit to construct and install the work herein described. Y This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC 1ON_ 111-4 5 ., .CENSUS TRACT ....... u Owner's Name .. �_ ��. �.C}... --�P------ ---- --- - -------------- Address.... �-/ . .[ �tLlic ...- City..- Ci one ......... ......... Contractor's Name ------ License # .Phone ---------- - Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------ - Number of living units- ------ - ------Number of bedrooms,--. _-_Garbage Grinder__-. -Lot Size----- .-/afi_7 ..... _ Water Supply: Public System and name--- _.--____... - ---- - ------- --------- ----•-- ------ - - �- Character of soil to a depth of 3 feet:/ Sand EJ Silt E] Clay E-] PeatEJ Son dy Loam ❑ Clay Loam ❑-- ---------- Private Hard Pon ❑n Adobe ❑ Fill 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 see age pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ]� 1��'/ -'.Ir i i [ Size ---------�� -- Liquid Depth -..._ ------------ - Capacity &410 Type- -Material-------- -----------------No. Compartments.-.---- Distance to nearest: Well - _- - - --��f- ------ ------ ---. b-- -----.Prop. Line .... -- LEACHING LINE [ No. of Lines_------------&--------- Length of each line-------5-14 -1-14- � Total Length --- .-. --- 'D' Box.----/----Type Filter Material-------13-I-_-..Depth Filter Material-..._!. ", ------- -_ ----------- Distance,to nearest: Well..-___--&Y Foundation_._ � .------Property Line SEEPAGE PIT [ Depth__ )AhDiameter---- -- . _ ----Number--------- ---3. Rock Filled Yese No❑ Water Table Depth..__...____.....- �---_ --- �<- --.Rock Size- --1 -'�---x �-------- � -�---- ---- Distance to nearest: Wells 1 --- ............Foundation.-------�-�'��---Prop. Line__) CIO �.�.--- REPAIR/ADDITION (Prev. Sanitation Permit#_.. - _ --------- ----------------- ----------Date- Septic Tank (Specify Requirements)_______ ___ ___________ Disposal Field (Specify Requirements)-...- - ------------ - --------- ------------------------------- -------------------- certify (Draw existing and required addition on reverse se side) - I herebycern 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, Vsholl not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed_.... "------------------ Y Owner _. R.-. BY G�< L�- \J- k2�_ --Title -E' '� ` =:.ecv., (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.-. ..f..... DATE DIVISION OF LAND NUMBER --- --------- • - - - ----- ---- -----------------------------------------DATE.------..... . ADDITIONAL COMMENTS_- ------------------------------------ - ----- ------------------------ ------ ----------- ------ ---- -- - ------ • -------- -------- -... -- - - - - --------------- Final Inspection by:-..-- EH P Y:---- --�---- - ---�-- - --------- -Date..._. � --..✓_._ . . EH 13 24 SAN IOAQUIN LOCA EALTH DISTRICT F85 21677 REV. 7/76 3M