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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FORTION PERMIT <br /> K ,�NIYAPermit <br /> r ----------------- .------------- - ---------------- (Complete in Triplicate) <br /> - <br /> ----------------------------------------- <br /> ---------- - bate Issued--- _/—/X-,7/ <br /> ----- <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 described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> - ------------------- <br /> T CENSUS TRAC .. <br /> JOB ADDRESS/LOCATION <br /> .- ----- --- Phone . : . <br /> Owners Name. - -- -- - -- --- --------- ---- ----- ------------ - --- <br /> ----------- ----------------- ------ --------- ----------- <br /> - !.� ----- ----------- ------ <br /> City zip <br /> Contractor's Name-} -: -} ------------------ <br /> C <br /> `. - en n � <br /> r t _Lic se Pho e. -- <br /> l ----------------- <br /> Installation;will~save: r : Residence � artment House E] Commercial ❑ Trailer Court ❑ ) <br /> Motel ❑ 'Other -------- ---- _ l <br /> € ;_.�. . <br /> Number of.(iving,units---=------- --Num -eY of.bedtooms�.="Garbage . <br /> Grind ex------------Lot Size-- --------------------------- <br /> ---- z <br /> L <br /> Water Supply: Public System.and name.---.-------'--- ------------- --------------------------------------_-------...__-----t--------..-------------=----;-------- Private i <br /> Character of soil to a depth of 3 feet: Sand ❑ -Silt ElClay ❑ Peat F] Sandy Loam E] Clay Loam E] <br /> r Hardpan El Adobe Fill Material if yes,�type----------------- --------- <br /> F �.� <br /> {Plot pian, showing size of lot,,location of system in relation to_wells, buildings, etc..must be placed on reverse side.] t <br /> " i <br /> - t. . —o_r1 .. . .ate <br /> NEW INSTALLATION: (No septic tank or )sfeg,pageit permitted if public sewer is available within 200 feet,) <br /> # x <br /> .-- Li Uid Depthth ----------------------- <br /> -SEPTIC TANK, - --- --- ---- <br /> PACKAGE TREATMENT <br /> / - atenal-- ' ` No.-Compartments ; <br /> Capacity----- -- - : P� M ------------------ <br /> Prop./ '! I <br /> )�J . J o ion `/� Line <br /> Distance .to nearest: VIle11 -- - '- -- = _ ,F Found <br /> LEACHING LINE.. [ ] No.,of Lines _:- ;.Length of each line _.... To#al Length..- <br /> iD' Box._/_:. -.Depth Filter Material- - :-- -- ---- --- --- - " <br /> T e Fitter Material -:-Y P <br /> Found ____ Pro erty tine <br /> Distance to nearest: Weil .... :-- "�" -" Filled Y <br /> Foundation P <br /> :. . .--- - :.-. ; Roc <br /> L SEEPAGE PIT [ ] Depth-_'-.1--:f Diameter ... Number...- _ es ❑ No❑ <br /> i <br /> Rock ' led <br /> i 1 Rock Size -------------------------- <br /> :Foundation <br /> - --------------------- <br /> Waters Table•Depth---------- ---------- - ,- : - <br /> ii ... - -- <br /> -------------=------= Foundation. Prop. Line <br /> ITIONSanitation Permit#---------------------- <br /> Distanceao nearest: Well__..--;-_....- <br /> REPAIR/ADD (Prev.{ Date=-- ---------------------------------------) <br /> ! - "---- ------------ ------ ------ .. <br /> Septic Tank (Specify Requirements)----- -------------- <br /> 4 ..-------- ---------------------------'-----..._- <br /> Disposal Field {Specify Requ.irements]..._���- -- -�--------"- -- <br /> I e -------- -- -- ---------- ----- ------ ---= -.-. ----- . - ---- ----- ------ - <br /> --- - <br /> --- - - - --- - - <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-County <br /> Ordinances, State Laws, onid Rules.and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "1 certify'that in "the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Work m 's Compensation- laws of California." <br /> --- - <br /> Signed-: r_ -- - , . = Own <br /> (M <br /> er <br /> ----- -:---,----------- <br /> i _ ---- ------------------- -------------------- <br /> Title - <br /> BY-;--- = - . r - t <br /> f7, (!f other than'owrier) <br /> t FO DEPARTMENT USE ONLY <br /> ir <br /> ------------------------------------DATE- - ------`- = �- <br /> APPLICATION A&EPTED BY_: <br /> DIVISION OF LAND NUMBER------- ------ -- - DATE = , <br /> ADDITIONAL COMMENTS- ----------------- ----- -------------• --- ---------------- <br /> --------------- <br /> --- ------- --------------------- -----------------------------'----------------------. ----------------- <br /> ---- ----------------------------------------- -----:-- <br /> _ --------------- <br /> ---- - ------------------- --- <br /> ------ ----- <br /> - Date i ......... <br /> -- -- <br /> Final Inspection b <br /> t. ------------------- <br /> p Y <br /> EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV.7/75 3M <br />