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FOR OFFICE USE: fICATI&W - '-SANITK -ARMIT)� <br /> AME TION E <br /> I Per'nit No. <br /> (Complle'Alq Triplicate) <br /> ---------- ------------------------------ <br /> - <br /> Date Issued --------- <br /> ----- --- ------ This'Permit Expires I Year From Date Issued <br /> ', <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and ihstaItthe work herein <br /> described. This application is made-in compliance with County Ordinance No. 549 afi&existing Rules'Nbnd Regulations. <br /> -----CENSUS TRACT T-------------- ...... <br /> JOB ADDRESS/LOC,�TIQN <br /> OVA ------------------ ---- -----Phone <br /> Owner's Name ------- - -6---------------------- ----------------------- I— , - <br /> I A991------------ --------------k---------------------- <br /> ---------- City <br /> -- <br /> Address --------- <br /> Licen'se #J-)-------------------- Phone ------- ------ --------------- <br /> C66'tractor's Name --- --------------- ----- --- A <br /> will serve. ResidenceWcirtment Houseo Commercial [aiaT er Court <br /> A-P <br /> Motella Other ------ ------------------------------- <br /> ' a- Grind ---- Lot Size - -----------------­ <br /> - <br /> Number of living units:------------ Number of bedragrns ------------Garbge k ----- ------------------ <br /> �_/'� Private 0 <br /> Water Supply: Public Syste MI ffeet <br /> meCharacter of soI toa depthof 3 : SO. 0, CIO y-Loam <br /> b'j­ y.0 Peat 0 Saridy Loam El Clay f <br /> ;24Adobet�[:] Fill Material --=-=------------------- <br /> _ <br /> - ------------------- <br /> Hardpan-, If yes;type ---- <br /> (Plot plan,' showing size of lot, location of system in relation to wells, 6uildingsf etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewerR available within 200 feetj <br /> PACKAGE TREATMENT SEPTIC TANK Size--------------------------- ------------ Liquid Depth -------- <br /> ---------- ............ <br /> Capacity ----------------- Type -------------------- Material--------- ci�'05m pa <br /> rtments <br /> Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line ---------- --------coo <br /> LEACHING LINE No. of Lines ------------------------ Length of each line-.-------L--k ----f�%ofcil Length ------------__J---------�j <br /> - ---------- <br /> -D' Box --- -------- Type Filter Material -------------------!Depth Filter Materi ----------------------------------- Tn <br /> _I----------------- Property Line ------- <br /> Distance to nearest: Well ------------------------ Foundation <br /> SEEPAGE PIT D.epth -------------- Diameter.,.--------- Nu ----- Rock Filled Yes C] No ED <br /> --------- ------ <br /> E. <br /> Water Table Depth ------ ----------------- -------------•Rock Size ----------------•--------------- <br /> Distance to nearest. Well Foundation --------------------- Prop. Line .------------- <br /> IDate ----------------------------------) <br /> Septic <br /> (Prev. Sanitatior! Permit ------- ---- ------------------------------ D( ----------- <br /> c - I -- --------------- -------------- ----- --_ <br /> ---------- ------- <br /> Septic Tank {Specify Requirements) _.------------- --- --- ------ I <br /> Requirements) ---------- ----- ------- ---—---------------------------------------------- <br /> Disposal Field (Specify <br /> -------------------------------------------------------------------------------- ---------- --I------ <br /> ------------------- ----------------------------------------------------- <br /> ------------ ------------------------------- <br /> --------------- <br /> ------------- ---------------- ------------------- ---- <br /> --- --- -- ----------- -- -- ---- <br /> reverse(Draw existing acid required addition on reee side) <br /> I hereby certify that I have prepared red this application _=d that the work wille 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 ;f the work for which this permit is issued, I shall not employ any person in such manner <br /> T Compensation laws of California." <br /> 'a's to become sublitct.to Workman, <br /> _-Owne <br /> Signed-- ------- --------------- <br /> .. ... .... ... <br /> ------------- <br /> By -------------- ------ - <br /> ----------------------------------- <br /> FOR DEPART Title'--'------- -------------- <br /> th `,.,owner) <br /> DEPARTMENT US ONLY <br /> DATE. ?$/------------------- <br /> APPLICATIONACCEPTED By --- ----------------------------------------------------------------------- <br /> BUILDING PERMIT ISSUED ------------------------------- - -- -------- <br /> - <br /> ADDITIONAL COMMENTS ---- <br /> - --------- ---------------I--------------------------------------------------- -------- --------------------------------------------------------------------- ------------- <br /> ----- -----------------------------------------I--------------------------------------------- -- <br /> -------- ------------------------------------------------17------------------------------------------- <br /> ----------------------- <br /> ----------------------------------------------------------------------------------------------------------i------------------------------------------------------i-------- ------------------------------ <br /> FinalInspection'by: ------------------------------------------------------------------------------------------------------------------------Date - -------------------------------------------- <br /> SAN JOAQUIN LOCAL ,HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />