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FQR OFFICE USE: <br /> APPLICATION FOR ZA ,TION PERMIT <br /> '^ - -� - ~` ~~~~Y-~�--(Completein Triplicate) � <br /> Permit No: <br /> =I -------------� E' ------ <br /> t I =: Date Issued -.-- <br /> -� - 7 <br /> --------------------------------------------.--""""____ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. 1 <br /> sy ---- <br /> ---------JOB ADDRESS/LOCATION-.� W ------- CENSUS TRACT <br /> Owner's Name <br /> t .- __ <br /> _ Phone-- - - --- ------------------------------ <br /> Address <br /> `- <br /> --- <br /> Addriess .. A , <br /> ------------------------------ City i ------ --------------------_--- <br /> Contractor's Name-"-- - --• ----'------- license #, .�`f/---'-- Phone _ -- ---- <br /> Instailation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other 1 ' <br /> Number of living units..__1__I__ Number of bedrooms ������ <br /> t ; ":_--Garbage Grinder ---- ""-"-� Lot Size -----L '� ` "'-_____________________• <br /> Water Supply: Public System ancl-name'- ----------------------------- / � -Private ❑ <br /> Character of soil to a depth of 3 feet: S nd'❑ Silt C] Clay❑ Peat❑ Sandy'l.oam ❑ Clay Loam ❑ <br /> s(Hardpan ❑ Adobe❑ Fill Material ------------ If yes,type ---------------------------- { <br /> {Plot plan, showing size'ofTot, location. of system in relatiari-to wells;buildings, etc.r 'ust be placed on reverse side.) �a <br /> NEW,fN5TALLATIONe {No septic.tan's r.seepage pit permitted"if public sewer is available within 200 feet,} <br /> F <br /> r, <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[],. ' �� Size'� `_.: _ ' � Liquid Depth -____"_."_""- <br /> s1 <br /> Capacity --------'T"'" ---- TYPe - -- --- Mate ----- '--- �No. Compartments <br /> - <br /> i . <br /> P = <br /> Distance to nearest:. Well------- == ==------ -""-� -Foundation __=-- -------------- Prop. Line ----------_-:-------- <br /> LEAC;NING LINE [ ] No. of Lines "-____"-.--"-_____- Length of each-line-------------------------- Total Length __------_-.---..._-_--_-_ <br /> ffi b' Box Type Filter Material Depth''_r_:_------_ Filter Material ------------------------------------ <br /> -"Distance <br /> ---------------------"__._ <br /> P --' ------------------------ on ------------------------ Property Line ------------•-••----••- <br /> ' r � <br /> crest: Well Foundation <br /> SEEPAGE PIT � � F Depth ce to ne <br /> ,__-__-- Diameter Number,--------------------_---_--_- Rock Filled Yes ❑ No <br /> .°Water Table Depth --------------------=---------------------------R ck Size -------------------------------- <br /> fDistance to nearest; Well ------------------------------------------Foundation --------------------- Prop. Line ----------- ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) '--- -----------------=------------------------------------------------------------------ ----------------------------------------------- I <br /> Disposal Fi d (Specify Requirements ----" <br /> J -- <br /> -------------- <br /> ----------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued; I shalt not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signe ------- ------ Owner <br /> BY ----------------- ---------------------- ----------- Title ----- <br /> (If other than owner) <br /> = EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . ------------------------------------------------------------. DATE j� rl <br /> BUILDINGPERMIT ISSUED ---- -- --------- ---------------------------------------------------------------DATE ------------------------------------------ <br /> AD T10 COMMENTS ------- --- --- ---- <br /> -----f <br /> y f ti; <br /> � t J -- „=-r--r----- - ori---�---- <br /> �ina Insp ction b � ) iia � t j y�� y <br /> !1_> .ate <br /> ------------------ ----- <br /> SAN JOAQUIN LOCAL HEALTH DIM(& <br /> E. H. 4 1-'68 Rev, 5M <br />