Laserfiche WebLink
FOR OFFICE USE: FOR OFFICE USE: R <br /> APPLICATION(Complete in <br /> PERMIT <br /> Triplicate) r Permit No._ _g'. -------- <br /> ----- <br /> -------------------------------- q <br /> " Date Issued_.5-2_-�_/.__ <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. i <br /> This application is made in compliance with County Ordinance No. 549 and'existing Rules and Regula <br /> JOB ADDRESS/LOCATION.:...-� r -------- -r-----f S.b---------- --lAf-�----— --=------------'------------ --- .CENSUS TRACT ' <br /> yo 2 1 <br /> 1 e M ---- --------------- -------- ------------- --- ------ <br /> .2,1 ,71' <br /> ---- Phone --------,­Owner's Name. 5-- F �-- i <br /> Address '� 'Z -x. >--:i�.R�HU-�. - City ��G ZiPZ���_$ <br /> .{.. y s <br /> Contractor's Name -- CPg [� -s------------- ---------- ----License #--------- C/� Phone <br /> lnstallation will serve: Residence X" Apartment House.❑ C-omercial ❑ Trailer Court ❑ i <br /> . ..:. • Motel ❑ Other--- = -------- <br /> 1 Ir/2- <br /> Number of living.units:"-:.__-__--____Number of bedrooms._._"/Garb! a Grinder.__ .-. Lot Size_'__.._-._.-__.__ ------ <br /> Water Supply: Public System-and nam: ` '- ovate (� <br /> PP Y _ <br /> ---- -- -- <br /> Character of soil to a depth of 3 feet: ' Sand paSilt❑ Clay ❑ ` Peat 0 Sandy Loam El Cay Loam ❑ h , k <br /> l Ha'rdp �❑ Adobe;❑ Fill Material'- <br /> _ __.._"..".If yes, type-._._--___: <br /> \ --------------------- <br /> (Plot plan, showing size of lot, location-,of system in,re-lation to wells, buildings, etc. must be-placed on reverse side.) <br /> x. <br /> NEW INSTALLATION: �(N6'septic tanr_seepag�jp pe mitted if public sewer is available within200 feet,! <br /> feet,! <br /> o1� <br /> Size �---x--'-----------x - y Liquid Depth ' �s------- <br /> PACKAGE <br /> �TREATMENT- [ ] i SEPTIC TANK' -[ 2, x <br /> 2e``R --Material=---C+3'hC•+-'7 partments <br /> \ No. Com <br /> ��. .. ._ <br /> Distance'.to-neare <br /> st: Weil-;-=-=--`1!U _ >�-----Foundation-_ -------=:".Prop. Line--------- -'-- <br /> ... - ------ <br /> Total Length <br /> LEACHING LINELength,of each nab ? 0 - <br /> -- - . ,[ � <br /> D' Box .. .. Type Filter Material...-1.V" _bepth�Filter Material....._ a <br /> Distance to riearest: Well I -- C�--- -Fo nclation �U ____.Property <br /> Linux$��`► <br /> SEEPAGE PIT [ ] Depth_ ._' _. Diameter_-... Number � � - ~ h`-=- = Rock;Fille KYess.Ej KNo ❑ <br /> .- <br /> ."._a... <br /> Water Table Depth----- --- - <br /> v <br /> �Rock�S,�� r 11 . . :,r ��. <br /> t ----- <br /> Distance #o nedrest: Weif----- ---_-- ---------=-------Foundation..__.--_ ,r Prop.- <br /> E :Date - ---.---1---�----- -._�-------- <br /> Septic <br /> ...�- M <br /> REPAIR/ADDITION (Prev -Sonitatlon-Permit#-.-- --=- .----------------------- <br /> - --------------------------------------------------- - <br /> 5eptec Tank {Specify:Requirements)---- --- =- --=-.--==- ::_- ��----- - ----------------- _ --=-�- ---=---� <br /> [ . ., <br /> _ I <br /> yL' <br /> T ------------- - - - <br /> Disposal Field (Specify.,Requirements}...." --------------- - = = <br /> ...... <br /> ..., <br /> -- Y -- ------------------- <br /> - <br /> -------- ----- <br /> --------- ----- <br /> t -- --------------- ------------------------ --------- ---- ------- ---------- ---- --------- ----------------- <br /> {Draw existing and required addition on reverse side](}r ; <br /> r <br /> I hereby certify that l have prepared this application and that the`work will be done in- ac rda ce with jSan-Joaquin County <br /> Ordinances,' State Laws, and .Rules and Regulations of the San Joaquin Local Health District.Home owner or licensed agents <br /> signature certifies the following: ; <br /> t.]. <br /> "I certify that in the performance of the rk for which this permit is issued, I shalt not Lploy;any person in such manner as <br /> to become subject to Workman's <br /> Corn <br /> !tion laws_ of California." - <br /> Signed ='. <br /> --- ------ --- - --- -------- -- --------------- ----- <br /> S .. <br /> !Owner �. r <br /> n ; <br /> .., <br /> i <br /> T + i <br /> (If other than ne'r) ] <br /> FjDRDPPARTMEl9T USE. ONLY <br /> - -----------' - --• - J ' --- <br /> APPLICATION ACCEPTED BY-:---------- DATEY.77 <br /> DIVISION OF LAND NUMBER.- ' ------- ---' = :.DATE. <br /> ---- - -- - ---- ' <br /> ADDITIONAL COMMENTS------'°'�� "q�-i vr_ .=_z _-?0 - ? <br /> ---------------------- - a <br /> -- ------------- ------------------ <br /> _; <br /> } 1y�--------- �i----- - r_/�X 'D Gy���"� �-----.IO�Q�.�DAt"L---- --------------- <br /> mal Ins ection b ------=-------------------- -r� - _ v -� <br /> "---"""-" - F&S 21677 REV. 7/76 3M <br /> P Date. ------•- 1- ��------- - -- --- -- <br /> �13 24 � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'r _U <br />