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FOR 4 FICE USE: 4� :� F <br /> ;; !n APPLICATION FOR RITATION PERMIT <br /> ---- - --- - (Complete in Triplicate) � Permit No: <br /> �] � (� Date Issue��"A�I_ <br /> .........41-1.Y V- ---------------------- 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 <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDR1.ESS/LOCATION ---ZLQ� -- P-`�� `` ------- --- --CENSUS TRACT -------------------------- <br /> "M t <br /> . . <br /> Name " �;.�``' [ -�-- -�-- ---------------------------------------=----- ---- --Phone ----------------------------- <br /> ., /� <br /> Address ---- �------- ---- ----�� - fJ�-------------- City ------- ------------------------------------------------ <br /> Contractor's Name,.-i-s � f License #��z=. �1` Phone' <br /> ------------------•-• --•- <br /> Installation will serve: Residence partment House❑ Commercial :❑Trailer Court ',❑ <br /> 1 1 Motel ❑ Other --------------- k <br /> --------------------------- <br /> Number of living units:------J.- Number._of-bedroorr`ri-------------Garbage Grinder.' Lot Size ------------------- <br /> Water Supply: Public System and name ---------- - ' -� t Private (1 <br /> ;= ------------------------------ ❑ V <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Clay Peat❑ Sandy Loam -E] Clay Loam C) h <br /> Hardpan ❑ Adobe Fill Material Q if yes,Type ------------------ ------ <br /> {Plot 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 /> i <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth _-_--_-----------_----.--. ; <br /> Capacity -------------------- Type -------------------- Material---------t------------ No. Compartments ---------_-•-------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------__--_-_----_- i <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line----------_.--------------- Total Length -----------_----_......... - <br /> 'D' Box -------.---- Type' Filter Material --------------------Depth Filter Material -------------------- -----• --- <br /> Distance to nearest: Well ------------------------ Foundation i--~ ------------------ Property Line <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table 'Depth'-----------TM - - ._.-... __ <br /> ---=------------------------Rock Size ------'-------------------------- <br /> .Distance <br /> ----------------- --- --Distance to nearest: Well ----------------------------------------Foundation -----------_- -.-- Prop. Line ---_----_.------------ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -----_.---__------------------------------ Date ---------------------------------- <br /> Septic <br /> -_-_--_----._-.-_ - i <br /> i <br /> � <br /> Septic Tank (Specify Requirements) ---------------- ----------------------------------------------- ----`=--------------------- d <br /> --------/------------ <br /> Disposal Field (Specify Requirements) ---.- --------------� % i!1'fQ ------------t------------------ - <br /> �� ----------------------------------------------------------------------------- <br /> --------- ----------------------------------------------------------------------------------------------- J <br /> {Draw existing and required addition on reverse side) _ <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 Workman's Compensation laws of California." <br /> Signed ------------------------------ - --------- �jJ� Owner <br /> �'��'��----- <br /> BY --------------- ----------------- - -- ------- ------------------------- Title - --� -------------------------------------------- <br /> (If oth an owner) <br /> O PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- --------------------- ...... - .........v------------- DATE �' f ------------ <br /> BUILDING PERMIT ISSUED -----r -=--- -- ------ ----------- -- -------DATE --- ----- ---------- <br /> ADDTIONA COMMENT--- --- --- ---- --- - -- -ti--- -- ------------------------------------------------- --------------------------------------------------------------- <br /> ------------------------------- ---------- --- - ------- - --- -----------------------------------------------_--------------------- ---------- --------------------------- ------- <br /> Final Inspection by: ----- ----- - -- - ---------------------------------------'�-----------------------------Date <br /> SAN OAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M ,' <br /> l <br />