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FOR OFFICE LISE, MA L FOR OFFICE USE- -74 APPLICATION FOR SA611TAT}ON PERMIT K412, • ICamplete in Triplicate] �6~�� ' �,�,.� , NQ,.... 7 -.�::s~r ...... This Permit Expires i Year From Date Issued uate Issued.. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application plication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 11 JOB ADDRESS/LOCATION ----- �_ - - .,_..._------CENSUS TRACT.-.--.--.- r - Owner's Name.. .. .tCi�/A,'�........ ----- J ! Address_ �r9._•5 .... os r_c.__'? 2c4... .D - City -a-------- ......zip.. 47X_AA44P------- Contractor's Nome.--------- --•-- ----•- License #-. --- . ..........Phone . .-----.----- Installation will serve: Residence®. Apartment House❑ Commercial ❑ Trailer Court ❑ -� Motel ❑ Other------------- "� Number of living units: ..._,/-. Number of bedrooms__.X_„•Garbage Grinder_../..-._Lot Water Supply_ Public System and name ._...._____________ _ Private rgy Character of sail to a depth of 3 feet: Sand 7 Silt El Clay EJ Peat n._ Sandy Loarn ❑ -YClay Loam--- Hardpan] Adobe [l Fill Material-------...,.lf yes, type._.._. .......... {Piot plan, showing sire of fat, locationof system it reldtirn to wells, buildings, etc_ must be plated on reverse side.) NEW INSTALLATION: (No septic tonk or seepage,;pit permitted if public sewer i voilable within 244 feet,l PACKAGE TREATMENT [ ] SEPTIC TANK' ., S«.ef�_ �p r --------- y ..-...,.....%4k)Liquid Depth._...__.. YCa aCIT JA . Type...:._..---. [.� Materlgl.- f !. fo. Compartments..... Distance to nearest: Well.. �Q_ -:..--------- ------_._Foundation-_-�Q.-_.-----------Prop, Line....� 1........ ......yr LEACHING LINE [ ] No. of Lines ;1., �/ ' • 1� Length of each line...--h!-Q--__••--•--- ,.Tarot Length .......... D' Bax....--------Type Filter Mate'tial....................-Depth Filter Material...------___........____ Distance to nearest: Welix,. s•'f ;� .Found atiori._-_•yc _-_-.----.Property Line-__'VC-11 ------------------- Depth -_- -----__--- •-•Depth 1!�...... .Diameter_ ---'-`"r_----.plumber.. ..` __.__•--___ Rock Filled Yes No ❑ UAA % rf Water Table Depth_.... .._..;._...__._._..!. ...............-.--Rock IX x /C, Distance to nearest: Well .; ; �---- _-- ---------------Found tion__ _75----__.___..__Prop. Line... --------- REPAIR/ADDITION {Prey. Sanitation Permit#.--- r �- Septic Tank (Specify Requirements)-- ... .. Disposal Field tS eci Requirements) -.. _- -.- --. - ----------------------- 3..�+-- G� ---- ..............- (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 CouJJnty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, F shall not employ any person in such manner as to becama bjetf o Workman's C�M�sal"ionlaws of CalifSigned__ By-------------_-- ------•---••------••-------- -••--•--•-------- •--- ---------...Title--- (If other than owners -- _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... . .... .. . . ---•--•-•-•-._........_._-- ADDITIONAL coMMl:rvTs.__. --•---------------..____._._. DATE.. .. - -•-- -7�.. ..._.._....� DIVISION OF LAND NUMBER.•.....................--••---... . -- DATE - - ........ -- - - --- .---•---•--------------�___^-- - - - - -- - - -- ... ---------------------------_---------------------------------•----_•-•---------- ------------•- ------------- --••-•••---------------------- ------ -- ......_- ---•-••------------•------ -- -- - ----------•-•- - Final Inspection by:-_-. .................------Date----_.. .. � .._......._..._ ---- ._... .. et 13 24 SAN J0AQL11 LOCAL HEALTH DISTRICT Fos 21677 rV 3M