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FOR OFFICE USE: APPLICATION FOR JTAT O PERMIT Permit - - ----- --------------------- (Complete in Triplicate) No. --------------------------------------------------------- This Permit Expires 1 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 maddee in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIIONI-40li;t/-.-^�__f_+�, /:4_-_�K S__i-Armlo _�APAa-VAACENSUS TRACT __-_--------------------- Owner's Name _- i/ - ---- �------- 1�'s.°.� 'ly-_ Phone J; - - -r ---- /`' Address CfA�------ -- -� ------c- -_ ,ee,.0 l ��O/ . CitY �E �'�L` vContractor's Name ,. ____f�i5�2 �5 ._O�� __________________.License # <! t ------ Phone _i .:.4 /.----- Installation will serve: Residence ❑Apartment House❑ Commercial []Trailer Court i❑ Motel E]Other _!!fid /`lG.. Number of living units:----l------ Number of bedrooms ---- ------Garbage Grinder ------------ Lot Size cS________________________ Water Supply: Public System and name ----------------------------------------------------------------- --------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'[-] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 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 on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size__--_-�KIO.--____-__________________ Liquid Depth _-_!S71�---_--___----- Capacity -1-0-----__ Type 'Material_-- No. Compartments ____0.............. Distance to nearest: Well _.SQ_ -__________________Foundation ---/40- ' ____ Prop. Line ....... LEACHING LINE [ ] No. of Lines --------l_____________ Length of each line----/l'Q------------- Total Length ---.1 40....... 'D' Box ------------ Type Filter Material Depth Filter Material -_____lam_~......................... Distance to nearest: Well ------- Foundation ------- Property Line ............ SEEPAGE PIT [ ) Depth __-.. _--___ Diameter 3(_`--__ Number ------ -------------- Rock Filled Yes No 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- . .. Distance to nearest: Well __/�D©_ _'i�.................Foun�Ic�tion ._��___t�----- Prop. Line .._�..'f'"..._._ REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ________--.---------___--_______._) Septic Tank (Specify Requirements) ____________---_-_-- Disposal Field (Specify Requirements) -__--_--____ _____________________________________ ------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and tequired 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---------- -------------------------------------------------------------------------- Owner BY ------- - ---- -------------------•---------------------- Title ------ --------------------------------------------------- (If her than owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _._____ ._. r- - �/ DATE ____ �I// -- -- F------------- �'�`"�----------- BUILDING PERMIT ISSUED -------- -------------------------�--- ------- -----------------------------DATE -----------------------------. . --- ------ ------ - - ----------- ADDITIONALCOMMENTS --- ----------------------------- --------- --------------------- -------------------------------------------------- --------- -----------I-------------------------------------- ---------------------------------------------------------- --------------------------------------------'-----�--------------------------------------------------- ----------------------------------------- -- - _ - �.�1Final Inspection by: ----------- -- ------ - ----------Date --- ---- --� ---- ------ SAN JOA16UIN LOCAL' HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M