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FOR OFFICE USE: APPLICATION EOR_5'iNITATION PERMIT ---------------------------------------------------`" - . . .� to f`--�7� (Complete in Triplicate) Permit No. _ _______________ } - -------------- This Permit Expires 1 Year From Date Issued Date Issued -' � Application is hereby made to the Sart Joaquin Local Health District for a permit to construct and install the work herein described. This"pplication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 4k, JOB ADDRESS/LOCATIONP_S-I' _ ,_. /�1_P �1_L ___L _-- _ _ t° /�_CENSUS TRACT -------7�_______________ Owner's Name -/------- -p -- f! - "------- ------ I r/U _I Phone � �J 3` 9 Address '/ 0r . City , q Contractor's Name -- -- - ._ -- __ _ ______ <__ - �___ �lV_G.License # ------------------------ Phoned Installation will serve: Residence 0�,Apartment House❑ Commercial ❑Trailer Court '❑ Motel ❑ Other ----------'----------------------------------- rr Number of living units.-C-)--- Number' of be'drooms __ _ Garbage Grinder �_1__ Lot Size ��__ZMA_�_�-'_____ "_....__.. Water Supply: Public System and name ---------------------------'-------------------------------------------------------------------------•----------Private Character of soil to a depth.'of 3 feet: Sand'❑ Silt❑» Clay ❑ Peat❑ Sandy Loam R 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: 1No septic tank or seepage pit permitted if public-sewer is available within 200 feet,) Z�! PACKAGE TREATMENT [ ] SEPTIC//T��A�/�1NK Size_ : l .___-_______________ Liquid Qepth S___________-_.-_-____ i �Copacity/_i<141i1_ _ Type' Material__( AL o. Compartments L___Z-- ._........ Distance to nearest: Well __�`� __ __.______-..Foundation _/Q_____________ Prop. Line -- ---------- LEACHING -- LEACHING LINE [�( No. of Lines [� ,__rilter. - S i --_-�- ------------ Length .:of eMrDepth- --�.�-- __-- TotalLength .�--�L�-.------ •-•-- «'D' Box - � 1 Type Filter Material l-Z- aterial _ ___�_____________________---.__........ Distance to nearest: Well ___` _________ Foundation __ S__-_______ Property Line ._.__._..__ o SEEPAGE PIT [ ] Depth __ _ ___ Diameter ---� Number _ �)__------------ Rock Filled Yes ,& No i❑ Water Table !Depth ---7-5----------------T-------------- -=:Rock-Size Distance to nearest: Well .___l--C)__v�_______________________Foundation __��_.0---------- Prop. Line _s.._~`...... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------11 Septic Tank (Specify Requirements) --- -------------------------------------------------------------------------------------- ------------------------------- Disposal Field {Specify Requirements) ------------- ------------------------------------------------------------- -------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that!" t e performance of the work for which this permit is issued, I shall not employ any person in such manner as to beta e sub ecttto Workman's Com insafiion laws of California." Signed _--- .�--_-L _ ------- --- Owner ------ -- By -------- ---- -rt (r4J i `------. --- D in r Title '---- Of other than owner) i MENT USE ONLY APPLICATION ACCEPTED BY - - -- ------ ---------- ------------------------------------- DATE _..__1-6 �c� '�---------- BUILDING PERMIT ISSUED __________ ______DATE ___________.______-__ ADDITIONAL CO MENTS 1 -- - ------ - - - -- ---- -- E # � � Qt -------------- --------- y ----------- f7 Fina! Inspection by: ________ __________-.Date ___ ------_-___-_ �- - ----------- y �i N JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M