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........ ..,... APPLICAItON Ft _ #NITATION PERMIT <br /> .................................................... IContpiate in Tripfkate! Permit No. . ..: G... <br /> ........................................... <br /> .. ... . ...................... .. . .. ... this Permit Expires t Year From Date Issued 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 wit County Ordinance No. 549 and existing Rules and Regulationse <br /> JOB ADDRESS/LOCATION .. (a.. = ••t........................... . ....CENSUS TRACT ........4................. <br /> Owner's Name ............ ..V:�.......................... .....................................Phone .................................... <br /> Address ..............................� .` -:- -""".--�~ --- ... •----------•-•'Cite -------•......................................... ................ ..... <br /> Contractor's Name s ... y....... • ......License � it 2-... Phone <br />` Installation will serves, esidence VApartment House Q Commercial OTrailer Court 0 <br /> Motel❑Other---------- ........... <br /> Number of living,unitk:............ Number of bedrooms .—Garbage Grinder Lot Sirs <br /> Water Supply: Public System and name I Private�— <br /> Character of soil to d depth of 3 feet: Sand❑ Sift❑ Clay 0 Peat❑ Sandy Loam 0 Clay Loom.0 <br /> Hardpan❑ Adobe❑ Filll.Material ............If yes,type ............... ............ <br /> p g ,si a of lot, <br /> (Plot tan, showin location of aysterr� in-relation,to wells, buitding:, etc. must be placed on reverse side.) <br /> NEW INSTAW4 IONt. (No septic,o seepagelpit permitted if public sewer is available within 2164 feet,) <br /> PACKAGE TREATMENT. [ ] SEPTIC TANK( Size.... ........................................... Liquid Depth .......................... <br /> : CapacityP .... Type ._ Material...................... No. Compartments _ _......,..... <br /> Distance to nearest: Well' /ll Foundation le Prop. Line ... <br /> LEACHING LINir No. of Lines ...�- --------------- Length of each line-.e..........._....... Total Length .244` . ........� <br /> l 'D' Box .1....... Type kilter Material ... -Depth Filter Material ,��..................................� <br /> r I - - <br /> 10 Distance to nearest: Well ...................Foundation ......................... Property Line ............._._........A <br /> r. SEEP E I Depth .................... Diameter ........... ; Number ............................ !tock Filled Yes p No <br /> Water Table Depth ... Rock Size �. <br /> --•--•---•-•-•-•--•-•--................. .......---................. <br /> ...Foundation ..... Prop. Line <br /> j Distance to nearest: Well ..................................... ._............. ......_............... <br /> I <br />�. REPAIR/ADDITION IPrev. Sanitation Permit# ................................ .......... Date .................................. <br /> Septic Tank (Specify Requirements! ............................................ ... ....................... ......................._... ........ .._.... <br /> r <br /> Disposal Field 6lSpecify Requirements --••............................ .. ........................•.........-----...............•........•............................... <br /> .......................... . . .. .................................................................. ........--••-•---------...........---•--............................................__.... . <br /> ............................. .. ................----.---..--•--................................... . ..._...-----...-----...----..........----•-..--................._......._..............._. . <br /> (Draw existing and required aiddition an reverse side) <br /> I hereby certify that l'have prepared this application and that thea work will he done In accordance with Son Joaquin <br />_ County Ordinancef, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Ilten•' <br /> sed agents signature certifies the following: <br /> "I.certify that In ttie performance of the work for which.this permit Is Issued, I shall not employ any person In such manner <br /> as to become ubl' t t�kman's Compensation laws of California." <br /> Signed Ow <br /> ner <br /> Y --- ....••--••............................••....... ............................. <br /> Alf other than owner! <br /> FOR DEPARTMFOY USE ONLY <br /> APPLICATION ACCEPTED BY --------................................ .:. DATE ...- .......................... <br /> BUILDING PERMIT ISSUED ..DATE ........................................... <br /> ADDITIONAL-'COMMENTS .................................................:.............................I.......I....... <br /> .................................................•-•-------------------•................------.........._..... ........................ ..._............-............................................... <br /> ........ <br /> ................ ...... <br /> Final Inspection by ...'Date ....... ........ ..�....................... <br /> EH 13 2h 1-68 Rev. 5m SAN JOAQUIN. LOCAL HEA H TRICT S,/?h r3M <br /> r`'r7y <br />