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POR of" USE: <br /> APKJCATM FOR SAMtTATM POW ��/7 <br /> -^ Formic No. ..... <br /> !Complete In Trtpncote► <br /> .. Date issued ..3.:.1 7. <br /> ..........r'', ,'.z� . ............ This Permit Expires 1 Year From Dais ksued <br /> Application is hereby mode to the San Joaquin local Health District for a permit to construct and install the work heroin <br /> described. This application is made 1n compliance with County Ordinance N`0 549 ext 1 Rules and Regutatlonst <br /> JOB ADDRESSAOCATb ............... . .........�....:.......4 t .`? ........... CENSUS TRAC'[ ...... ......... <br /> Owner's Name ............. C. ...................... .I..............�i or►s . .. ........... <br /> . ^ `. <br /> Address .............. t....t �...:.... .. ........................City .... <br /> Contractor's Name -e%�kf: s.�..�i.,. -: :�.. i:�::...........license# .�:� .. Phone .:z�.'. ... <br /> installation will serves Residence C�(Aporbnont House Q Commercial Moller Court 0 <br /> ` Moro!❑Obiter........... <br /> ....�.....-...-�inder .:��::. lot Sise . .�..z�-�-��- � <br /> Number of living units:.....,! .. Number of .:f-... rbags .. ........... <br /> Water Supply= Public System and name , .... ......._......... ...... ................Private❑ <br /> Character of soil to a depth of 3 foots Sand E3 Silt Q Clay Q Peat❑ SandY Loam fl Clay loan"Q <br /> Hardpan❑ Adobe 0 Fill Material ............If yes,type............... ............ <br /> d <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, otc. 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 [ J SEPTIC TANK; Sizs.: .., .. •. :'� ---. .... . Liquid Depth ...35....�............ <br /> Capoclty/20!-C G ftC TYI� Materiol.6.:.' No. Compartments .2.............. <br /> . Distance to. nearest= Well &-f...........Foundation ./p............Prop..Line....:4-...11... <br /> LEACHING LiNE { No. of lines ../.................. Length of .�, line..,l� .............. Total Length 1 .fes-.-:............ <br /> 'D' Box . ,' ..: Type Filter Material ��* .�'-..--.Depth. Fiber Material .AR"_............................ <br /> ..... <br /> . 10Di:tonce to nearosts Weil :`.`�::` f . Foundation ,fCf f:........... Property Lute .... .......... <br /> SEEPAGE PiT [ Depth :: .. �..... Di r. Number ......./ ...... <br /> ...... .... Rock Filled Yes! No 0 <br /> Water Table Depth .................................Rock Size ..Z`........................ <br /> Distance to nearestt Well ' .........Foundatiaa ...... Prop. Line .......... <br /> REPAIR/ADDITION(Prov. Sanitation Permit¢ ............................................ Date ..................................1 <br /> SepticTank (SpodfV Requirements) ......................................... .......................................................................................... <br /> Disposal Field (Specify Requirements) <br /> ......................................... .............................................................................................. .......................................................... <br /> .......... .Drexisting........................................... . aw g ond r«iquired addition on reverse iidel. ... ............................................... . <br /> t <br /> I hereby certify that I have prepared this application and that the work will be dope in accordonas whit San Jeagtdn <br /> County Ordinances, State taws, and Rules and Reguk4ons of the San Joaquin Local t eolith aisirllat.H~owner er Ilcem• <br /> sed agents signature certifies the followings <br /> "I certify that in the performanco of the work for which this permit is issued, I shall not employ OW Perlin to such mwnme <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ...... . ? .. . ........................ Owner <br /> By ............. � ._ '�..�. --: ............ title ...... , .e...... . . .� ...... .......... <br /> pf other than owner! <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... . .. . . ......�.Z ............................................................ DATE . '. '..,Z.7................. <br /> BUILDINGPERMIT ISSUED..................... ..............................DATE .............................._............ <br /> ADDiTiONAL COMMENTS ......... . .... ...%............. <br /> .. ............................ . .................... ............ <br /> .................................................� .--------- ...... ................................................................... .................................................... <br /> : :":..:. . ' ........................_............. ...I....._................... .... .................. <br /> Final inspection by: "'. .. .............. .......... ........................ M . ..:. ........ .................. <br /> EH 13 24 1-6f p Rev. 5H SAN JOAQUiN LOCAL HEALTH DISTRICT 8/7h 3M <br /> �ilZ <br />