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FOR OFFICE USE: j! �°'� '" FOR OFFICE USE- <br /> V7 <br /> W�L�F ITATION PERMIT <br /> Permit No.-_rf-�— <br /> ---------- ---------- ---------- ------------------------ (Com lete in Triplica, 1 <br /> ----------- -------------------- - r fg-A-" +l¢' Date Issued---�-3-d---- . <br /> This Permit Expires 1 Year From Date Issued <br /> r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regp�lations: <br /> ------- CENSUS TRACT--------------- ------.-- . <br /> JOB ADDRESS/LOCATION ------h-- -Q-"`--� �------�e=----- ------------------ --- ---- - <br /> Phone--------- ------ ----------- -- <br /> Owner's Name------ -+ , / 1 ... . <br /> --------- ------C1 - <br /> Address----- - ------------- tY-- - "f -y ---- ---- ---- -­- -zip------------- <br /> ---------- <br /> Contractor's License #-";' -I ,�''.._Phone_, _ �- <br /> ' <br /> Installation will,serve: Residence [A Apartment House F-1Commercial ❑ Trailer Court ❑ � <br /> }_ ... Motel ❑ Other-'--.-.*,. -- ---------------- <br /> ----Garbage Grinder---- -------Lot Size . G�/}/ '! <br /> Number of living units:------�_-------Number of.bedrooms.---,� , <br /> Private <br /> --------------------- - <br /> Water Supply: Public System and name --------------------------------------------- <br /> . <br /> Character of soil to a depth of 3 feet: - Sand E] Silt[I _Clay El Peat❑ Sandy Loam E] Clay Loam ❑ t <br /> F <br /> Hardpan F-1Adobe �' Fill Material--.---------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 /> ALt< <br /> * ---------- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size. .+ `- --�"- ' ' `"---------_Liquid Depth._- ---- <br />' Capacityl,7 4 -- Type ---------------- Material .----=---=------=-= --No. Compartments------------9,------------------ <br /> Distanceao nearest: Well--.=-�-�'-�--------=•----------OFoundation ��-�----_=-- -Prop. Line.-._�--�---------- - -- <br /> f t t e ° r <br /> LEACHING LINE •je Na.,of Lines—:------ ----- ---------.Length of each line.-------- Q=-----:-.---- Total Len- .------ - --=---- Y <br /> 4 ----------------- ---------------- <br /> - Material_.--_ �f f�` th Filter Material D' Box- --�- ---TYpe -------- <br /> Filter -t ,��: : ; p..,F r -� - . <br /> i Distance to nearest Well A <br /> L S ' -,.uA "'. •Y�' a ---' <br /> T -=�--- -�-�--- --..Foundation ---- �-,�----------- Property Line -----� -=----- ------- <br /> SEEPAGE PIT [ ] p f Rock Filled Yes o <br /> . Depth ; ---=----Diameter --------- --- ----Number ---------- �----------- - � - <br /> Water Table Depth---i ---- ------=----------------- _ <br /> Rock -Size---------------------=--------------------------' <br /> . - r <br /> Distance to nearest: Well - - �.Foundation---------------------- ---Prop. Line--------------- ------------ <br /> i REPAIR/ADDITION (Prev, Sanitation Permit# ------------=-------------`------------------ Date- = 1 r: <br /> Tank (specify Requirements} ''r �' �� L•er* --------------- -------------- --------=-------- <br /> Septic = <br /> +..- <br /> Disposal Field (Specify Requirements)._ -""-- - --- �" '" ------------ <br /> ----------------------- <br /> ----------- <br /> ----- <br /> ------------------- <br /> i --------------- -------------------------------------------------------- - - ------ ------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared ithis application and that the-work will be done in accordance with San Joaquin County' <br /> tions of the San Joaquin Local Health District, Home owner or, licensed agents\ <br /> Ordinances,' State Laws, and Rules 'and Regula . <br /> signature certifies the following: <br /> P <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 as <br /> to become �S415"IMI to,Workman's-Compensation laws of California.' <br /> Signed l = <br /> - --------owner <br /> ry E ----:Title ------ -------= ---------------------------------- ---- ----- --- <br /> BY------- -- -- -------------------------- ------------------- ------------- ----- <br /> - <br /> (lf-other than..owner) ._ .. <br /> FOR DEPARTMENT USE ONLY. <br /> DATE ----- ` ------ <br /> APPLICATION ACCEPTED 13''1' . - ! <br /> DIVISION OF LAND NUMBER.-- = <br /> -----.DATE-------------------=----- --- ------------ <br /> ADDITIONAL COMMENTS----------- -------- ------- ------------ --------------------- ------------- ----- <br /> - ---------- - - <br /> -----------------.- <br /> ------- --- ------- --- -------------------- ----- <br /> } -- ------------------------------ <br /> -------------- y <br /> P n_ --------------- <br /> y l ., Date <br /> Final lns ection b - - - - ----- <br /> p y:------- ��' <br /> F&5 21677 REV/7/�+3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT �� <br />