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J 3 FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SAMTATION PERMIT � 7 f6 /1 ' ------------- --------------- ---------------- " (Complete in Triplicate) Permit No.................. ------------------------ - --------- Date Issued.-�=- .. ..-"7 ] ...-....____________________________________ _________ _ 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. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: GG d 7 Ao olc U(Yla Z/R Ae�------------ JOB ADDRESS/LOCATION... .../Q-- ------ ---------------------- --- CENSUS TRACT-----------..------------ Owner's Name..:.-IJ s-� �- E', Lcr/ �---------- ------------- ---------- - ----Phone-- -- ----- 4 Address----- V.0q- �On['f _i_ - -----------------Ci at d to Zi - 1 +Y .. - P —Contr'actor's -License #----------- ----------------Phone---------------------------------- Installation ------------------------------ -Installation will serve: Residence gj Apartment House[] Commercial D Jrailer Court ❑ Motel ❑ Other---------------------------------------------- Number --- ---------------------------------------Number of living units:------4---------Number of bedrooms...3-----Garbage Grinder---X-----Lot Size...............................................__.____.---- Water Supply: Public System and name----- L0"Vdie ------A)0,4L'xP----,05T_,& --------- ------------- --- -------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam K Clay Loam ❑ Hardpan ❑ 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 seepage pit permitted if public sewer is available within 200 feet,) 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.-----------------------------Total Length --------- ---------------------------- 'D' Box Type Filter Material....................Depth Filter Material......-----------_---___-._____--_-__- Distance to nearest: Well----------------------------Foundation.---_-------- ------- Property Line__-_______________----------_- I SEEPAGE PIT [ ] Depth-------------_Diameter..............-------Number-------------------------------- Rock Filled Yes ❑ No WaterTable Depth--------------------- ------------------------------------Rock Size------------ ----------------------------------- Distance to nearest: Weil--------------------- ------------------"Foundation.------------------------.Prop, Line--------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#--------------------_`i------------Y�--------!:-.Date----------------------------------------------1 f Septic Tank (Specify Requirements)------------------------------------- ------------------f------ --------------------------------------------------------- --- --- Disposal Field (Specify Requirements)-------------------- "- -------------- --- ---------------------------------------- ---------------------------------------------------------- ------------------------------x------------------ -------- ----------------------------- ------------------------------------------------------- { J 'Y i1 - f ------------------------------------- (Draw ---- - ................._.....-... ----------------------------------------------------- ----------_ _________ ________.___._...__________._____......._....-..._-._._ ..-...-.....__ _ .. (Draw existing and required addition,on reverse side) hereby certify that I have prepared this application an`d that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and egula:tions of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: t "I certify th 'n the perfornianc f ha ark for which-this-permitis--issued, I shall not employ any person in such manner as to becom subject to W rkma L ensation laws of California." Signed. -- ---Owner BY r ----- - ==------------ Title ------------------------------------------ f other than ownee) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ — ,_ -----�----- -� ----------------------------------------------------- -----------DATE.----- DIVISION OF LAND NUMBER.-: ---------- --- ------ ---- ------ --- ------ -- DATE --- ---------- - ------------------------------ 77:17 - -------------------- - ADDITIONAL COMMENTS.----7=_ -7.7 -_-- - - 1 --------------------------------------- ------------------------ � '�il+. ---------------------------------------------------------- _ } ------------------------------------ liter- Date. ---- ------------------- -- -- --- ------------------------- Final Inspection by:..... EH 13 24 SAN JOAQUIN LOCAL HEALTH DI TRICT 1./� F&5 21677 REV. 7/75 3M