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F9R OFFICE USE.' <br /> APPLICATION' 4ANIT <br /> --- ATION PERMIT <br /> ------------ <br /> ------ ---------------_7_"e ------- (Complete in Triplicate) <br /> Permit No. V <br /> ------------ ------ t, : ThisPermitExpires I Year From Date Issued Date Issued <br /> -------------------- <br /> Application ibis 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. <br /> JOB ADDRESS/LOCAT-I­9N 549 and existing Rules and Regulations.. <br /> Owner's Name ---- -----���------------.CENSUS TRACT -------------- --------- <br /> L!61_-_Se--- -------- -------C ZV_ -------A, <br /> Address ----------------- OP ---------------------- r•--- <br /> ----- ------- - <br /> ------------Phone ------------------------------------ <br /> ---(--------- city <br /> Contractor's Name . <br /> ------------------------------*--------- <br /> - <br /> --------- - <br /> - ----------------------------------------License #IA�f Phone <br /> Installation will serve: Residence <br /> [OAPart�ent HouseC] Commercial []Tral ler Court <br /> Motel El Other <br /> Number of living units ------ Number of bedrooms ---Garbage Grinder'­� Lot Size <br /> Water Supply, Public System and name ---------------- <br /> Character of.soil to a depth of 3 feet: Sand[I Silt E] GaY_------------F ------------- ------------- --------------I-------------------Private <br /> I Peat 0 Sandy Loam -E] Clay Loam.[] <br /> Hardpan El Adobe E1,-Fri—rZ-6terial if yes, type <br /> ------------------__----_ - <br /> (Plot plan, showing size of lot, location Of system in relation to wells, buildings, etc. must be Placed on reverse side.) <br /> --N XA <br /> . .EW INSTALLATION: (No septic tank or seepage pit permiftid`lf�-Public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT -SEPTIC TANK <br /> ------------- --- ------ Liquid Depth <br /> Capacity T e Materia! - ------------ <br /> yp <br /> 6_11 -1-0--NO. Compartments "_-Z------- <br /> Distance to near St., Well ----S557 --- <br /> ------------ <br /> LEACHING LINE No. of Lin -------------------Foundation ------/a-------- Prop. Line's--- <br /> -Is ---- ------ Length of each lira#-' Total Length A51) <br /> 'D' Box e--'!,- Type Filter Material I f I------------*-------------- <br /> Wth Filter Material ---' <br /> 4 <br /> Distance/tO nearest, Well -------- ------ ------- -------- <br /> -------------- Foundation _el��? t _/ <br /> _6 <br /> SEEPAGE PIT Depth Property Line --------------------- <br /> -------- Diameter Number -------- ------------ Rock Filled Ye <br /> Water Table Depth ---------6_9 'i ' s Q-_'__NO <br /> ---R6ck Size /Ze-77�-f il <br /> Distance to nearest., Well ------ I------------------Foundation -------- <br /> ---- Prop. Line._. <br /> REPAIR/ADDITION(Prev. Sanitation Permit -------- ---------------- - ----------------- <br /> -------------------- Date <br /> ------------- <br /> Septic Tank (Specify Requirements) ------------------- <br /> Disposal Field (Specify Requ- i.rements) ---------------------------------------------------------- <br /> -------------------------------------------- <br /> ------------------------------------------------ <br /> ------------------ ------------------------------------- -------------------------------------------------- ------------------------------------------------------------------------------------------------------ <br /> --------------------------- -------- --------------- ------ ------------------------------------------- -------------- <br /> fDraw existing and required-addition-o-n--reverse-side)- <br /> -------------------------------------------------------- <br /> I hereby certify that I have Prepared this application and that the work will be done 'in accordance with .Son 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 /> certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----- <br /> si I------- ------ ------------ Owner <br /> y -------------------------------- ----[ 'a- , A <br /> &-r------- <br /> (If other t- ------------------ Title ----- <br /> h --------------------- <br /> ------------------ <br /> FOR DEPARTMENT, USE ONLY <br /> APPLICATION ACCEPTED BY -.--r -------------------- 155, 77 <br /> -------------- ------ <br /> BUILDING PERMIT ISSUED DATE <br /> ADDITIONALCOMMENTS ----ir---------------- --------------------------------------------------------------------DATE <br /> ------------------ -------------------- ----------------------------------------------- <br /> ---------------------- <br /> ----------- <br /> ------------------------ --- ----- _,7%--------------P-) ------------ <br /> -------------------------------------- <br /> ----------------- ------- <br /> ,:----------------------------------------------------------------------------------------------- <br /> --- ---- --------- ----------------------------------------------- <br /> - ----------- --------- ----------4----------------------------------------------- --------------- -------- <br /> Final Inspection by, ------------------------------------------------------ <br /> ---------- -------- <br /> 11 -------------------------------------------------------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 7-'68 Rev. 5M <br />