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FOR OFFICE USE: APPLICATION FO&,;'A_t4ITATION PERMIT Permit No: _V-313_____--___ _ (Complete in Triplicate) ' ____-___- 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 --� ____-- ----! .! ---{- ---------------------_-----------.----------"_"--CENSUS TRACT _ _�__.__---- - Owner's Name ----�411; / �'�'! -------Phone ------ Address ID r'-----71-------- ----------------------------------------_. City -k--- - -----------------------------"---------------------•---------- - -r�� Contractor's Name ------1;4-'"'-'`---`---------------------------------------------------------- -=--------License # --------- -------------- Phone•--- =------,•----------------- Installation will serve: Residence L�Apartment House f❑ Commercial:❑Trailer Court ❑ Motel ❑Other ---------------------------------- Number --------------------------------Number of living units:-----1------ Number of bedrooms __-�-------Garbage Grinder ------------ Lot Size ____'------------ Water ____________ _.Water Supply: Public System and name ------------------------------------------------------------- ----------------------------------------------..Private ❑ Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat❑ Sandy Loam } Clay Loam;❑ Hardpan ❑ Adobe ❑ Fill Material ------------ 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 permitted if public sewer is available within 200 feet,) � PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] � Size-------------------------------------------------- Liquid Depth ---------.......---------- a s Capacity _ -----,_-_ Type ____________________ Material-------------- ------ No. Compartments ---------------.--_---- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --.----.-•---_--.-•_-- ` LEACHING LINE [ ] No, of Lines _______________________ Length of each line---------------------------- Total Length _______________---------__-- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------- Distance to nearest: Well ________________________ Foundation ------------------------ Property Line __________ ......... SEEPAGE PIT, [ ] Depth ---- __________ Diameter ________________ Number __-_______ ----------------- Rock Fillet! Yes Q Na11-1 Water Table Depth ------------------------------------------------Rock Size -------------------------------- k Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- If REPAIRJADDITION(Prev. Sanitation Permit# ____________________________________________ Date -----------------------------------) Septic Tank (Specify Requirements) -------------------._____-----________________ Disposal Field (Specify Requirements) ---- --------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ t ---------------------------------------------------.�.=--------- (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.Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Wo�rJkman's ompensation laws of California." Signed - / t- - - --- - -----}-- Owner « BY -------------------------"-- Title ----------- ------- ------------------------- (If other than owner) I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY ---- _ _•r• ------- ---------------- DATE _Y21.1.4.,.-_-•------------- --------------------------------------- BUILDING PERMIT ISSUED -------------------------------------------------------------------------------------------=--------- ----DATE ------------------------------------------- ADDITIONAL COMMENTS ._____"________ - ----•------------------ --------------------------- ---- - - Final Inspection -- _ . --------- --------------------------- -------------_------------------------------- - ---- ---------------- _ = S -. l - -------- - -------- - ---------------------------- pY "E -------------------------------------------------------------------------- ----Date - ------•--------- �y SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.