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k FOR OFFICE USE: FOR OFFICE USE: APPLICATION:FOR.SAN ITATICAPERMIT Permit No._-7J7_.�..- --------------- (Compl ----------------- eie.in Triplicate) ---------------- Date Issued.-5"16-"- ------------------ This Permit Expires 1 Year From Date Issued I Health District fora ermit:to construct an Application is hereby made to the San Joaquin Loco d,instakl the work herein described. This application is made in compliance with Coun#y Ordiriance',No. 549.-and existing Rules and Regulations: + (� 'a ----.CEN CT T ! CENSUS TRA JOB ADDRESS/.LOCATION. o ------- ----- ------- ------ t . Ph ne - ." -- C>`+vner's Name. �'�"_ Zip Address 3/aj:: I-L 19 ------ ------ City Contractor's Name------- _ �- ------ ------- ------- --License 7-/------ Contractor's Installation will.server Residence . Apartrrlenf'House❑"Commerciah❑=Frailer Court ❑ ' .Motel ❑ Other------------=-- -----------=--=--- ---------- 3 1 Number of living units:....... .......Number of bedrooms_[-A--Garbage Grinder-...-_"._.- Lot.Size--- f- -- � , 1 1 -------------------Private ❑ Public S stem and name-.-.;-- - -------------------- [ Water Supply:r of soil to a depth of 3 feet, Sand Y # l 0 Clay Peat Sandy Loam-❑ -C1dy,•Loam Characte ❑ Sit ❑ ❑ . Hardpan.❑ . Adobe ❑ Fill Material._---------1f yes, type----------- c. must be placed on reverse side.) (Plot plan, showing size of lot, location of system in relation to wells, buildings, et } NEW INSTALLATION:— {Nod septic tank or seepage pit permitted if public sewer is available within 200 feet,) ize_�.. Li—uid"Depth--4- ------------------- ----- -- PACKAGE TREATMENT [ ]' SEPTIC TANK [ 1 r' Matwial No. Compartments_.-__" .- ------ Co achy-�a��s�-- -`TYpe= - ------- ---- � --- - - � - - p , f r � - - -------------------Foundation ----` -- - - ` .P.ro Line-_---��- ------ -� Distance to nearest: Well..-.. L Total Length a�--------------------- =-i LEACHING LINE:, [ .1.., No. of Lines.,_,.f- : Len. of each line.,, �Q"� f + 'D' Box--:------:--TYk?e Filter Material--------------------Depth Filter Material--------------------------------- 'D' ---,---------.---- -L.n--- � [ e.-._ Distance to nearest: Well__.- _ Foundation._ .r ----- Property h `k Roc Filled Yes J�} No Depth;Z-A t U-uD� eter : Number - �E-RIT L ) / ------------------- - ----------- ---.Rock Size:--- -/ - f -- ------- : Water Table�Depth----- - - ! Distance to nearest: Well. -- - ------ = ------Foundation_f" .Prop. Line-----�----------------` lI' --- ----------Date------ ------------------ r REPAIR/ADDITION-(Prev. Sanitation-Permit#-------------- ---------------- ----- _ 4 Septic Tank (Specify Requirements)..__..._:- ---- - --'----- ------------ - -------------------- -- o Disposal Field (specify Requirements)_ ;,, ; - --------------------------- ---- --- - --------------------. { t- r'--`--- - ------- --- ---- - ---- -- - y � f (Draw existing and required addition on reverse side) ' r I hereby certify that I have-prepared 'this application and that the work will ILbe a�dHeal}„District. Home;owner orJlicensed agenoaquin ts Ordinances, State Laws; and Rules and Regulations of the..San Joaquint signature certifies the following: `erson in such manner as "I Certify that in the performance Iof the work for which this permit is','issued, I shall noi_employ any p to become subject to Workman's' Compensation laws of California.". I : awner Signed -. ---- ---- ---- - --- --- --- - - � --- --- ---- ---------------- ` t ------- Title----------------------- ------ By- {lf other than owner) I FOR-DEPARTMENT USE ONLY _ T DATE ------`-------.- DATE ------------ -------------------APPLICATION ACCEPTED BY.;--- ---� DIVISION OF LAND NUMBER---------------- " ADDITIONAL COMMENTS ' - ------------ ---- -------- ------ ------- --------------- -------------=- ---------- --------- -- - - -------------------------------------------------------- I ---- ---------------- ----------------------- - --------- t D �- -- "---- ------ _ -�� ate "----- - ------------- - - Final-Inspection by::. -- -- ---- ----- - --- - - F&s 21677 REV. 7/76 3A EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT