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FOR OFFICE USE: <br /> APPLICATION FOR.. PERMIT <br /> -----------------;4.�--------------------------------------- * '" -1,1111 Permit No <br /> I bte) IF <br /> (complete in Triplicate) <br /> --------------- --------------- <br /> ----- This Permit Expires I Year From Date Issued <br /> ----------- 4-11-0 -------------- <br /> Date Issued74 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ,ADDRESS/LOC-PON --------Z/ ------- ---- -- -------------CENSUS TRACT -------------- ........... <br /> Cb ------------------- <br /> -------- 10V t;_.gr ----------------Phone------------------ <br /> Owner's Name --- ---------------- .!!:r_ - -_ <br /> City <br /> --------------------------------------- <br /> Address ---------------------- ----- <br /> # Phone <br /> Contractor's Name -----i�A_s________::_______-License <br /> Installation will serge: Residenceartment HouseF] Commercial E]Trailer Court C1 <br /> Motel F-1 Other -------------------------------------------- <br /> Number of living units:-----)I.,_,Number-of Jedrooms ----Qarbage Grind=__A_e!Q__ Lot Size ......... <br /> f '64 <br /> Water Supply: Public System and name --- _rt�l------- ----_------------------ ...Private F1 <br /> Character of soil to a depth of 3 feet: Sand'E] Silt E3 Clay r-] Peat F] Sandy L am ❑ Clay Loam E] <br /> Hardpan ❑ Adobe EX rill M-ateriqL,4-l%.___ if yes,type ___________________ <br /> --------- <br /> plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK![ Size_________________________________.________.__ Liquid Depth -_-________-. <br /> Capacity ----------------- Type -------------------- Material---------------------- Na. Compartments ----- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ............. <br /> --- ---- ------- <br /> LEACHING LINE No. of Lines ----------- ------------ Length of each line________-_______________ Total Length --- <br /> 'D' Box ------------ Type Filter Material -----_______________Depth' <br /> -- ------ ---Depth' Filter Material -------------------- <br /> ------------ ....... <br /> Distance to nearest: Well ------------------------Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT Depth ------------------ Diameter -------------- WAIrnber ---------------------------- Rock Filled Yes E] No 0 <br /> _'-...-_-_-Rock Size ------------------ <br /> Water Table Depth ------- <br /> --------------- <br /> Distance to nearest: Well -------------------- -------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------t" <br /> --------------------- <br /> Septic Tank (Specify Requirements) ------------------------------ ---------- ------------ --------------------------- ------------------------ <br /> -- <br /> Disposal Field (Specify Requirements) ------ ---- --------­------- <br /> _S_; <br /> ---------- --- ---- --- -- - ---- ------------ <br /> ----l --------e -----4-1-1---------------------------------------------------I------- <br /> (Draw existing and required addition n reverse si e)* le* <br /> I hereby certify that I have prepared this -application and that the work will be done in accordance With San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Vgzf_9han's Compensation laws of California." <br /> Signed -----------10A -4, -- <br /> �, <br /> ------ Owner <br /> 4 <br /> '4 <br /> By ------------------------------------- __' - -Z-11 / ..% -.1------------- ---------------------------- <br /> --- ----- Title 45��Adv--- <br /> ilf other own FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY� 'red---- -a-r--ti-------------------------------------------------- DATE ---- <br /> BUILDINGPERMIT ISSUED -------------------------------------------------------------------------------___________________________DATE -----------------------------------ADDITIONAL COMMENTS ------------------------ --------r-------------- ---------------------------- --------------------------------------------------- ----------- <br /> ------- -------------------------------------------------------/---I-----7-------------C)-A----------------------------------------------------------------------------I---------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------- ---------- <br /> -------------------------------------- ----------;;;;&-- --------------------------- ----------------------------------1------------------------------- ------- <br /> Final Inspection by: ----- --- - --- ------- - - - ----Date -------V------------------ ---I <br /> SAN JnA UIN LOCAL HEALTH DISTRICT <br /> 4T <br /> E. H. 9 1-'68 Rev. 5M <br />