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z FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANlt`ATI05,PERMIT . .. �, ,. p (Complete in Triplicate) Permit No. C-- l 0 . ---------------------________--_--------------------- This Permit Expires•1 Year From Date Issued 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 --- ---- /ITJ.1f7111IRQ�-----.--R-P. ------.CENSUS TRACT---------- ------ Ov✓ner's Name----------' - V-/'i.&'- x LZ-------------------- ------------------- ----- -Phone ---------- ---- --- -- e: /j Address r- _,..:_ }_. Ci Y ti tY1 - -- i p- -- Contractor's Name-1 1, x - --- - '__ .License #--- .-- Phone., I -- Installation will l serve- : Residence] , Apartment H66-w.] Commercial ❑' Trailer Court ❑ .N I � r � `Number of.living u _ �Numer of,'b droo"s- -- Garbage Grinder_-_ --:._,,.Lot * _ . Wateri Supply:.Publif Syste� and nameI. - `" _ ---- ---- ----------------------------------- --------Private d p ❑ ' Fill Nlaterial____..1____._If es; type ---------- 7 -la - __ - Character of soil to d depth of 3 feet: 'i Sand ❑ Silt ❑ :Clays❑ Peat ❑ Sandy Loam�' Cla.y Loam 0 4 Hard an Adobe ❑ _ Y Yp - ---- t� (Plat plan, showing size of'lot, location of,system in relation to wells, buildings,-etc. must be placed on reverse side.) t t k .1 Ff f<'-. f i t NEW INSTALLA71'ON:� #.(No(septic tank`iir,seepage pit permitted if public sewer is available witliin.200 feet NEW PACKAGE TREATMENT '[ ]:. SEPTIC TANK-41Sh ; pth._� -- ___ qu I � . 63;------------ Capacity/c -Typea � c1st---.Materia[ _- -- No. Compartments-- ------------ ----- ., Distance to nearest: Well.' --Y ---_ 1 .. �.. _ r�s1 [ � E-, � � F'oundat,ion_ LEACHING LINE- [ ] Na. of Lines.'+-�; `- ' .;_- -..:,Lengthrof Bach line � !_- _ -__ -.T,.otal Length.__ _ - __ 'D'{Box-/ Feer Material �/r°'��-.De ox_ Tpth Filter Matenai__ C- __ _ _-_. ______-_ �. _ _.__-_ \\ 11 A� VVV y: Distance;to nearest: Weli :., c'2 -------------Foundation _....____.Property Line.__.__ j . SEEPAGE PIF [ ] De Diameter- _- ----.Number ---- s : Rock Filled Yes ❑ Noy❑ + p :: . + ;� Water TableD�pth - ----- � �`� ' Rock Size Distance.to rieor-est 1Nell __-_ ------ _:____._.Foundation_ *_ Prop. Line------------------------ 0 _______________________ P REPAIR/ADDITION (Prey:Sanitation Pe�rnit- ----= '--------- ------------.Date Septic Tank (Specify Requirements) - f - ---------------------------------' ----- - --------------- ------- --- -- -------- Disposal ------------= = Disposal Field (Specify Requirements) I---- ---------- -------- = ----- ---------------------'------------------------- -------- ---'----- -------------------------------------- --- --- - --- ---------- -------- ( t , - - -- - --------------------- ------- - ------- - ----- --------- - ----- -- --- . -- --- -•- ---- - I ' (Draw existing and required additionon reverse side[ t �I hereby certify that',l have prepared this application and that:the-work- will-be done in accordance with San Joaquin County Ordinances, State Daws, andRT Rules and Regulations of the San Joaquin Local Health_District. Home owner or licensed agents signature certifies the following: [ r , I certify that in the performance of'the work for whichthis_permit is issued, `I shall not employ any pers in such manner as ] to become subject W man' Compensation'"I w of. Calif ro nia.. 1 ` � - � - e _. Sagned-__ _ .Qwn p By---------------- ------------------. --- ---- ------ --=------ _.Title----- -------- ---- -- ---- - --------- ---- I ( other than ner] :_.. (If r: t fFOR"DEPARTMENT USE ONLY: t APPLICATION ACCEPTED BY --------------- ------------------I-------------DATE ---- -------- --- DIVISION OF LAND NUMBER:---------'-------------J- ---------- ---- ---------- - --------- ---' -- [ DATE----------- ------------------------------ --------.-- ADDITIONAL COMMENTS---------------- --=------------------------------ ----------------- t .- --- ----- -{ � ------- ----------------- - -- - - -- - -- - - - --- --- --------------------- ------ ----------------------- - ---- - --------- ------ ------------ ----------- ---------------------------------------------- --- -------------- ----------------------Final-Inspection bY --------------------- Date. EH 13 24SAN JOAQUIN LOCAL HEALTH:DISTRICT F&5 2167 REV. 7/76 3M