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1 ... --tea -r` __ -�'mtlFPk•/+d��—_ tip�1, FOR' OFFICE USE- �� i '__ ......... ............ APPLICATION FOR nANpli ate®N PERMIT No. _..7.,.5..:. 3 1 i (Com lete �. ..........•- i This Permit Expires } 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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION ,._.. . . _.. >- l ate• i -.......--•-•--........CENSUS TRACT Owner's Name .. .� " Phone . ............................ •f!• rL-.._....... Cit Y ---•------•-••---•-------• -•------•-•....................•. ............... Contractor's Name a - gym] I .__----- - --�•--•- ---�.------._.. ...__---....license # ?.�.+�.,.��r_---- Phone ��..� Installation will serve: Residence partment House❑ Commercial ❑Trailer Court 0 Motel ❑Other .............=................. -.............. � ; Number of living units.... 2—Number' of bedr s . .....Gar age Grinder ___. Lot Size ./� .._`_.- Water Supply: Public System and name ---_-----_ ".......... _-- - -.---.........•.... .............................Privote ❑ Character of soli to a depth of 3 feet: Sand Z] Silt❑ Clay ❑ 'Peat❑ Sandy Loam ❑ Clay Loam ❑ r 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-an reverse side.) 4 N€W INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200.feet,# PACKAGE _ ' TREATMENT ( ] SEPTIC TANK I ] Size-------- '__•--•--_-----------------.________ Liquid Depth ......................... Capacity Capacity ..:................. Type .................... Material---------------------- No. Compartments '...................... i Distance to nearest: Well - -••-• -•---••----Foundation ---------------------- Prop. Line}....................... 6 _____ Len th' of each line_________________ _______ _ __ Total Length ._.___.._._...._.._ ......... LEACHING.LINE [ ) No. of lines g - f ` """"'D'"i3ox-- --------- Type Filter Material F Yp --------------------Depth Filter•"Mdterial................................... .•---..:... rn Distance to nearest: Well _______________•__,, ... Foundation ....-_-,................ Property Line ........--.-_----:_---- " SEEPAGE PIT [ ) Depth .._•_._........_. Diameter ---------------- Number ........____ ............... Rock Filled Yes ❑ No [ Water.Table. Depth .............• ........Rock Size ........................_....... Distance to'nearest: Well ----------..............----............Foundation --•----------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation`Permit# ............-------------------------------- Date .................._........... .---) i .Septic Tank (Specify Requirements) .............. --•. ........ .. ......./ --------------- ....f .............. . • _ 1 Disposal Field (Specify Requirements) -----•----/�--------1-••-- ---•--. ` ..... ----- ......................................... _ j ._ ..... ------------------ ........................... (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 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 Workman's Compensation laws of California." Signed ................ Owner Lr....... . title other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .._ . ..........: -___-- -- DATES.—�.��_._�-.- BUILDING PERMIT ISSUED ...............• •---=-------= ..................................... ............_DATE ........................................... ADDITIONAL COMMENTS ........:.................... .............:.......................... . ._...... :-- --- --- - -----•...------•__ -,.. . -- •-• • -- ....._. . •• ....................... •- ----,.................. ., - ---••• . "_..• ? _....--- ---- ..................... --- Final Inspection by: ...- ... ... .......•-• -- •--...---•--•. ........................ .. .. ... } SAN JOAQUIN L CAL HEALTH_ DISTRICT. C U 13 24 7 �L� �S___ C11 � a...- - � � • w 1 11n '] �e �