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FOR OFFICE USE: FOR OFFICE USE: \(Complete in Triplicate) Permit No__ _______________ -------- --------------- -- ------------------------=--- �� Date Issued- - � --------------------------------------------------------- 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 exis 'ng Rules and Regulations: • # JOB ADDRESS/LOC TION." 'I__� ------- ----------- . ....... ..... ........ _ ......CENSUS - i Owner's Nam :- Name ------------- -• -, ------ Phone_ Address-`-6 / 1._ city.- —l zip Contractor's Name- -�P --- - -----I----------- License #_ �. - Phone:_ . s Installation will$serve:- a Residence [- [y]� Apartment House E) ;Commercial ❑ ;Trailer:Court ❑ i a7 Motel- E] Other---,-- '; Number of living units:_._./-----Number.of bedrooms -_--Garbage Grander Lot Size--- 4-.- -------------------------- ----- .-- -__ Water Supply: Public System and name . - ---1 .. --- --------------------------- Private; C Character of soil to a depth of 3 feet: Sand ❑ Silt❑ -Clay [] ; 'Peaf❑ Sandy Loam ❑ Clay Loam s Hardpan ❑ Adobe❑ Fill Materia L_.___'.___ 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 tpermitted if public sewer is available within 200 feet,J . PACKAGE TREATMENT. •'[..] t SEPTIC TANK" [.1 "Size ------ ---------------------------I-----Liquid Depth------- ------- --- Capacity-----------------------TYPe------------' "Material s �'- No: �ompaftments----=---------- ----------------- r. Distance`to nearest: Well------------- -----Foundation- ---- I----=------_---- Prop.•Line ' ----------------- 1 ' [ l No. of Lines- ------=------------=-----.Length of each line _ - --:.---_.--_:--_- ---..:--:7otW Len' th----------_- --�------- LEACH WG LINE.', , D' Box------------Type Filter Material--------------------Depth Filter Material...---------------------------=---------------------------- Distanceto nearest: Well-{--------------------------Foundation__-__.-._-_.""""_____ _S____.Propeity Line""_-"__._"-__. - f i SEEPAGE PIT [ ] Depth.__.:------------- Diameter -------------Number----------- -------_.------ r } Rock Filled . Yes ❑ Nof❑ l .• P ---- ----- - . f u.ock Size-----------' -•------------------- 5 Fo ..) . ( Distance to nearest Well -------------------=------r--.- R dation---"�'' ------------`_Prop. } --- )Line----------------- "REPAIR/ADDITION (Prev. Sanitation Permit# ------____:_. ----__:D . ------= ----=----- kr II f ----------------- :_ ----- --= Septic Tank (Specify Requirements).' _ st --------------------- - Dis€posal Field (Specify Requirements)--------------- - r ---- ---=- ------------ -- -- ------- --- - - --- �. - -------- ------------------------ Ile / ---------------------------------- ------------- - __ _____ _ ___ -------------------ji { ,.-----------------_---------------- _ __ ----_____e__-------------------------------.____________-__-_"_ -"__________- _---------------------------_.....__.._ _ _""-.________--_-------_---_--------_---_-- [ i (Draw existing and required-addition on'reverse side) y I hereby certify that 1 have prepared this application and that.the 'work will be done in accordancewith 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: .y "I cerci that in the � � � 1e�. ,certify performance of`the work for which this permit is issued,.l shall not employ any person in such manner as Signed p i --- ��•. _�'�-- - - --- Y. � 'r • togbeco su e . to an's om ensation; laws of California.'!Owner BY �G=Q- - T�` -- - --- - ---------- (if __ ._ y _f -_ (If other than.owndr) '. . . - r t f FOR DEPARTMENT USE ONLY, APPLICATION ACCEPTED BY_,_:°.-- rDATE----- ----- 4-- ------------- -- --- ------------------- ----- -- -- DMSION OF LAN D ..�' { = :�; : - :�..` _, '_: - : - --- -----------=- - ------------------------r ADDITIONAL COMMENTS-ER -- ---------------------"----- _------ ------------------ yDATE = ' _ - X01 '- �4 -i_ ~,- ------------- ----------- w�r�- __ _ __ ----- - - - �} _ Final Inspectian'byc ---------- -•----.Date..."_d - _- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21 rw�i76 inn