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t FOR OFFICE USE. FOR OFFICE USE: APPLICATION AFOR UMITATION PERMIT Permit No.�l-_ ��-- -- �--------- -------�-- -----�---- ----------- - (Complete in Triplicate) Date Issued__------------------ �_ �FL 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..... _ _CENSUS TRACT _--- Owner's Name...... -- -`-T7�-------- -------------- -- --- ------ ---------- --- -- ----------- - -------- Phone --- Address--- SM.� -------- ------------- --------------- city-.T-T ' ------------------------ Contractor's Name------ -- ------- ------- ----------------------------------- License -------- -- ---- -----------Phone-- ----------------- ---------- - Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------ ----- ------------ --------------------- r ---Garbo "C,._ ------- Number of living units:______!_____-___Number of bedrooms__._ ---Garbage Grinder Size-_..- ------- Water Supply: Public System and name--------------- 4:Private [I Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑= Clay Loam 2 . Hardpan ❑ Adobe ❑ Fill Material-. --------- 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 pubblicr sewer is available w�et 2D0 feet,] - Depth.- �-i--+- --- PACKAGE TREATMENT SEPTIC TANK Size----S �--1 �-x`5-- ------------- =Liquid Capacityl,2O O -------- ----------- ----No. Compartme gg Distance to nearest: Well__.__C�U-------------------------------Foundation.__lt3________-. .__=Prop. Line._/0-Q.. ---------- aa r 3 Length of each line ------ - LEACHING LINE N ------------Total Length._'. -70----------------------- [ ] o. of Lines-----__.__________--__ I _ q `-`.----------------- D' Box.__-!.______Type Filter Material/3-57.X�.�--Depth-Fester'iVlaterial_-____.__--�'-.___,_�. -�- Distance to nearest: Well.---U-V_ ________-__--Foundation__20__._____.. r.___Property Line:---------------------- SEEPAGE PIT [ ] Depth----------------Diameter--------.-----------Number--------------------------------4' RockrFilled Yes [3No C] WaterTable Depth --------------------------------------------------------Rock Size=-----'- --------------- ------------------- + Distancd'to nearest: Well---- -- ----------------------------------Foundation-------------------------.Prop. Line----- --------------------- REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------------- ---------Date----.-------------------------- --------------) Septic Tank (Specify Requirements)----.---------__.------------------------------------------------- ---------------------------------- Disposal Field (Specify Requirements)------------------ --------- -------------------------------------_. ----------------------------- ---------------------------------------------------- --------------------------------------------- ---------------------------------------------------------------------- -------------------------------------------------------------------------------- ----------------- ---------- ---------------- ------------ (Draw - - - ------------------------------------------------------------------ (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 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, I shall not employ any person in such manner as to become object to orkmanIs Compensation laws of California." Signed. _.. -. -----------------Owner By (1____ ------- ---------------- _ ---�----Title- - ---- --�-------- ---------- � - (If other than owner) FOR DEPARTMRNT USE ONLY APPLICATION ACCEPTED BY__- ___ DATE - - - - DIVISION OF LAND NUMBER ----------- _--DATE--------- --- ------------- -------------- ---- ADDITIONAL COMMENTS--------------------- --------------------------- ---------------- -------------------------------- -- ----------------------------------- Final Inspection b _Date .-- _ _-" -- "- ?�------- ---- - ----- - - ---------------------- --- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M