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i. FOR OFFICE USE: <br />'F -- r .... .. .. _ _ _ .... . <br /> APPLICATION <br /> ,.�_.FOR SAN pvNPSR <br /> .. lCopliPermit No. 2 �S"�- <br /> �•..,4.-,. m• � ..... ,.„,�,,,,, <br /> 3 1 ., ' . this Permit Expires t Year Icro ti <br /> • . .. - ns <br /> at*issued Date lasued <br /> Y t * <br /> r i <br /> Application it-hereby made to the'San.Jaaquin,local Healtli'District.�for'6� permit to, construct and Install the 'work her in <br /> described;This application Is madein"compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> s # i # <br /> JOB ADDRESS/LQCAN€ Z <br /> .._.. <br /> Owner's Name ...� � � � ._..CENSUS TRACT..----.-.---- - <br /> -�.. ,. .._ - ........ Phone ... <br /> Address .?....... ./ �{7.7✓... -r . ' - 11. ' i ,.. <br /> {. # <br /> Contractor' .... - <br /> s Name' - ? ' .: T <br /> �j` ` ..._...License # ..� �Phone . <br /> installation will serve: ` itesidence f Apar#men#House flComm ................. <br /> - <br /> p r r k atrial}]Trailer Court Q <br /> Motel Q Other f F. <br /> I Y <br /> Number of twin ---•- ...._. , , <br /> g units:_.._/.J Nunsber of bedrooms _..:.-.Garbage Grinder <br /> (. ! : 9 - <br /> Lot Size :..---��=;c���'"r� <br /> Water Su t ! . P -- - <br /> pp y ublic System and name _ <br /> Character of.soil.#o a depth`of 3#eat: Sand Q ' Sitt.Q Clay Q; p Q Sandy --- .... va <br /> Pri to ` <br /> I _ Loam Clay Loam Q <br /> f Hardpan[Q Adobe 1 fill.Material ... ........ If yes,type...... ` <br /> (Plat plan, showing size of lot, location of sy4tem in relation to weNs; buildings, etc. must be placed on reverse aide.) <br /> NEW INSTALLATION: ( <br /> No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE.TREATMENT. -( lj ! <br /> SEPTIC TANK f l # Size <br /> a ........-• •--------- ------ Liquid Depth ......... _ . . <br /> ' Capacity . f -----------i Type .. •- _- . -- Material- ...�_.._.------ :No. Compartments . <br /> Distance to Dearest: Well ___... <br /> i <br /> T _ :..Fou <br /> nd <br /> LEACHING LINE 4 -••-• -- <br /> l Na. of lines ..'.--- ' ng <br /> of.each Line...:--- <br /> Prop. Line <br /> i -�.. sa .., Total Length ..........-•--........ . <br /> D' Box <br /> .... ------ Type Filter-Material --•-- <br /> P Depthf filter Material <br /> F Distance to'nearest., Well <br /> Foundi5tion <br /> SEEPAGE PIT �I } � .... ....... ... Property .......... , <br /> SPIT Depth Diameter Number ` <br /> line <br /> -••--•--- <br /> (tock Filled Yes Q <br /> Water Table Depth .................... .................Rock Size • d No {] <br /> 3 .... <br /> r Distance to nearest: Well ` <br /> :_=• -- <br /> y L <br /> f <br /> REPAIR/ADDITION.{Prev. Sanitation Permit E i n® ................ <br /> onn 1' op. L 1 <br /> .. # .. : .. -- Date • ............... ` •} - <br /> Septic-Tank (Speci.fy,.Requlrements) .. :.... 9 <br /> ` ............ ........... .............. <br /> posal Field (Specify -Requirements) <br /> Vj <br /> ---------------- <br /> : o € {Draw existing and required adds}tion'on reverse side) .. <br /> I hereby certify that I have.prepared:this.applItatian and,that.the work will be done in �aceordaisce with Saes Joaquin <br /> County Ordinances, State Laws; and Rules and'Regulations of the San Joaquin :Local Health:Dlsteict:Name owner or liter- <br /> sed agents signature certifies the following: '" �,r. `' <br /> asI certify.that in the.performance of the work.for whirls this .permit is issued; Ik all not employ any person in such manner <br /> to become <br /> subject to Workman's Compensation laws of CaliFornia." <br /> e . . , . " <br /> � -:---•,�---� - .. <br /> caner r <br /> _____________________ ^''-�'"� .• 1. 9 <br /> (If.other than owner s:. - <br /> # FOR DEPARTMENT USE ONLY • 3 <br /> i <br /> APPLICATIQ_ N 'ACCEPTED: BY ...'.... g t <br /> BUILDING PERMIT ISSUED - ' . ._. _.,DATE, ...� .�� ! <br /> ----- <br /> ----•-. ..... ......... ....DATE • _' ......... <br /> ADDITIONAL COMMENTS ........ <br /> ---..--•--- <br /> ---------- <br /> ---------- --------- ----------------••-----•---•-----•--•--•--- --•--•---• ------................ ------------..........1- ............ .......... ----------_,.. <br /> 3 <br /> Final Inspection by: -•-----------• -- ---- r.....------' <br /> Date _S 5_..J.._ _.....�_.---------- <br /> EH 13 2!I 1-6�3 Rev. 5m - � ---------------------------- - �_ ,...-- --------------. __.�...__..- ---- •--- - , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />