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_ FOR OFFICE usE: e FOR OFFICE USE: APPLICAT_ ION FOIUSANIVATION PERMIT 7?_, 76 / Permit No---------- ----- ------ (Complete in Triplicate) _ _ ---- ----------- -- Date Issued-.- --�/-7 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: {. JOB ADDRESS/LOCATION. Q ------------------ --- CENSUS TRACT --- -------- ------------ /� / ,_ --------------------------------------------------Phone----------------------------------- Owner s Name.._�1,� �--- ��S-----=--.l..��---- -- ci ------- ----- ----------------zip---------------- F6_�--- 4 ----------------- -------- �v Address----- - ---j9" -- { LT Z ,�/� License #._�3�_ -- ----- Phone-_.97-7— Contractor's Name v -/ --------- Lv_l . �y Installation will serve: Residence Apartment House.M Commercial [:] Trailer Court F1 Motel ❑ Other---=-----------=------- ---=- --- ------- Numbe'r of living units;.___-.------Number of bed rooms--�.�----Garbage Grinder•------------Lot Size---..------- Private - .: Water Supply: Public System and name--------------------------------------------------------- ---------------------------- --- - Character of soil:to a depth of 3 feet: Sand [ISilt❑ Clay El Pea t ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material-. .--------i yes, type-------------- ------- ----- i `""- Tbuildings, etc. must be_placed on reverse side.) (P1ot plan, showing size of lot, location of system in relati"on to vv'el�s, � NEW INSTALLATION: (No'septic tank or seepage pit'permitted if public sewer is available within 200 feet,) rt l PACKAGE TREATMENT [ ) SEPTIC NK QV Size-------------- ---------------------------------- ---------Liquid Depth..--------- `'*�. ^^No-Com artments----=-- ------- F Capacci y- -------- d TYPe Distancek-to nearest: Well---------- ------- ------------------------Fou d tiory-= Prop. Line---- ------------ ' f Q'5-------.Total Length._.- ----- ---- LEACHING LINE No. of Lines.-.__ "__.----------------Length of each line.___"""_-- 1 D' Box---/------=p :lter Mat�rial:__------------- Depth Filter Material--------------------------------------------loundation--- ------- ---------------.Pro er Line ---------- --------------------- Distanceto neI- --X- p Yes No SUS s SEEP Depth---- s---------Diamet - ------f-----Number---'------------------------------- Rock Fill ❑ ❑__ t. Water Tai le Depth-----------.---------------------------------------- --- Rock Size : Distance to nearest: Well-"------:-----------.---------.--------------Foundation------------------------- Prop. Line. e -------------------- Date. ---------> --------- --------- ----- REPAIR/ADDITION (Prev. Sanitation Permit#-___-----'------------- ________ __ -------- Septic _ Septic Tank (Specify Requirements) �. - ---- 1 f r�400 - T! Disposal Field (Specify Requirements)---------�i��----- - -------- -------------- ' ------ -------- --- -"-- ' --- j ----- ------------------------------------------------------ = -------- .� i (Draw existing and required addition on reverse side)`. R I hereby certify that I have prepared this application and drat(the work wilt be done,in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of thej'Si'ii oaqVil-�L'Eo'cal-Health-District:j'Home owner or licensed agentsI. 71 signature certifies the following: _ i i "I certify that in the— a e f the wok r which this permitAs issued, I shall not employ any person in such manner to become s ect to W rkman's Compensation laws of Cali form . .� f Signed- - Own I{ _ - -- ------- Title-_ --------------_ --------------------- r - - - -------- (if-other than owner)N. . F DEPARTMENT USE ONLY _ / - ----DATE.---- -- �� = 7-------- APPLICATION ACCEPTED BY- "! /-- ---- - ---- -- ---- -- ---- ----"--- DATE DIVISION OF LAND NUMBER. ................... ------------------------------ -- ------- ADDITIONAL COMMENTS----------- -------------------- -------------------------"---------------- l --------------------------------- ------------------------------------------------- -------- p --------- --- --------- -- ---------------------------------------------------------------- !7� --------------- - --- Date - ------ ---,--- �---- - - Final Inspection b --------------------------------- - -- ------------------ -------- - ---- Fay 21677 REV.7/76 3M EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT