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- FOR OFFICE USE: "' APPLICATION FOR 1AF41TATION PERMIT " t Permit No. .7Z- - _. (Complete in Triplicate) } --------- ---------------------------------------------- Date Issued 5-1 --------------------_-- This Permit Expires 1 Year From 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 �.1 '1� ff{ ----------------=------------- --------------- CENSUS TRACT -�y� _-----Phone __ � -p ------ Owner's Name oll. -------- /_�1� ----------------•--- --------- + � ----- Address . ------------------ - -----------. city ' J Te f�/. -------------- r� a Contractor's Name .l S� ---� ' 1 ---------------------License # 17/2 _3---- Phone -- Installation will serve: Residence ❑ Apartment House❑ Commercial ;❑Traildr Court i❑ Motel ❑ Other ------------------- ----------------------- Number of living units:--/------ Number of bedrooms ____.Garbage Grinder Vv--- Lot Size/4r--"X--7_5 ---------------- Water Supply: Public System and name ----------------------------- Private ❑ ----------- - --- t Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ 1 Peat❑ Sandy Loam -❑ Clay Lou Im i. Hardpan ❑ Adobe Fill Material ------------ If yes,type _---__.___--------- - --- --, 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed"}n reverse side.} k NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200�4eetJ PACKAGE TREATMENT {.7 SEPTIC TANK[ Size--�.-------------------------------------------- -Liquid Depth ----------- --------------- d Capacity ------ ------------ Type -------------------- Material---------------------- No. Compartments ------------ ----:---- Distance to nearest: Well ------------------------------------Foundation --------------- - -•- Prop. Line :--------_• -----..._ 1' LEACHING LINE [ ] No, of Lines ------------------------ Length of each line---------------------------- Total Length+--.-______-,________---- f 'D' Box ------------ Type Filter Material ____________________Depth Filter Material __---________-___________-________-..___-_ I Distance to nearest: Well ________________________ Foundation __�--------------------- Property Line ______________._._____ z SEEPAGE PIT [ ] Depth --__---- ---------- Diameter ---------------- Number __.-------------------------- Rock Filled Yes ❑ No i❑ eWater Table Depth --------------------------------------- --------Rock Size -------------------------------- I Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------•--------_--- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -----------------------------------1 ( Septic Tank (Specify Requirements) -----------_ Disposal Field (5pecify Requirements) --------�--=.�- ------ �/ t/g - 3U-.---------------- ----------------------------------------------------------------=------------------------------ _-------- I ----------i----------------------------- -------------------- ---=-------------- --------------------------------------------------------------------------------------------- (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'Healih 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, I shall not employ any person in such manner as to become subject to Wor an's Compensation laws of California." i Signed ------------------ -- ----- --------- A--- -------------- FOR-DEPARTMENT USE-ONLY Owner -C--------------- Title - .-------------------- -- - -------------------------------------------- (If other, an owner FOR DEPARTMENT USE ONLY --- --------------APPLICATION ACCEPTED ------- DATE ` -------------- BUILDING BUILDING PERMIT ISSUED ------------------------------------------------ -------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ------ ----------- ----------------------------------------- ----------------------------------------------------------- ------------------------------------- - q x / ----------- --------------------------------------------------------- fJ ------- -------- -- / -1---------- --- - ----- ------------------ - -------- ------------------------- r- - 3 Final Inspection by: ______-- -- - -- Date ---- r -- -- ------ -------- -- - _ -- t . SAN JOAQUIN OCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M