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t FOR OFFICE USE: {i-"' ,- APPLICATION F4 TA71QN PERMIT --- - -------- _ ________________• (Complete in Triplicate} Permit No. 7 4-1 0 -------- r ----------------------------------------- This Permit Expires I Year From Date Issued Date Issued __ .:7ZF� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATION ___. I � f -- -- �-`d------------------------------------CENSUS TRACT Owner's Name - Z� { --- - P one Address ___ --------- i --- - --------------------- CityContractor's Name __ -� ? . X ----------------------------------- - - - - - - - cense #��..� 2-- Phone Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court ;❑ y Motel ❑Other ----------------------------- ............... Number of living uni,ts:__/----- Number of bedrooms -- ---------Garbage Grinder - '_��Lot Size Water Supply:PP Y: Public-System and name �---------------�,-----_- _-- - -_-.- _ ---------------------------- - ---Private' Character of soil to a depth of 3 feet: Sand❑ Sift❑ Cla . Y ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ [Adobe ` Fill Material _.____._.___ If es, rY type ----- ---------- -------- (Plot plan, showing size of loft, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION:i (No septic tank or seepage pit permitted if public`ewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK' i p- y ' T Size_ , - Liquid Depth ` ! --------- j -------- 1,. YP. Ca acit �__ e _ _6 Material_ "_ No. Compartments P i Distance to nearestAWelll ___-_ _- .. Foundation _. ------------ Prop. Line"-. LEACHING LINE �1 No. of Lines r.v_r-__--_____- �, - _ -Length of each line___a,.�--___-_----_ Total Length 4 ® 9 00 --------------- t I D' Bo�Xj, .�__:Type Filter rMateria Depth Filter Material -------------------------------- - Dista nearest: Well ar b - �__ Foundation . _. ` —/ ------------- Property Line _/ .___ .___-_ SEEPAGE PIT �} I Depth_-- Diameter%"-- Number ___ ----------- Rock Filled YeSA No 0 Water Table Depth ____ Vis. _ ____ ------------------Rock Size/-- -rf Distance to near@st:;Well., . ._ _ -- !F � -------------------- Foundation�A�----- Prop. Line _/reP__....._.... REPAIR/ADDITION{Prev. Sanitation. Perrni't# -------------------a_-_----_.- - Date -------------------------- 1 " kSPeSe tic TancifY-Re uirements} _------------ - ------------------- , --- ---------ars osaFie`ld (SPPcify Requirements) !� ! ., yj - { = .& -- --------------- ._ _. _� Y. ___________________ _ _--_{.__--- ------------------------------------------ (Draw existing and required addition on reverse side) t I hereby certify that I have prepared this application and that the workwill be done in• accord'an e_with.•5an, Joaquin ; County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licen- sed agents signature certifies the following: _ "I certify that in the performance of the work for which this permit 7.s issued, I shall not employ any person in such manner as to become subject to Workman`s Compensatlon laws of Caiifornla." Signed - ---------------1 _ Owner - ---------- -- BY ------ ------------- -- - -- -----� --------------- Title Z '� -------- ----------------------- R ------- - -- {if oth an owner) -- - - ---- R RTMENT USE ONLY APPLICATION ACCEPTED BY BUILDING PERMIT ISSUED ----------- ------ -- - DATE ___,_ - --77��r-7f---------- ADDI ONAL COMMENT --- --- - ------ TE ---------------- ---------- ------------------------- -------- ------ ------- - ------------------------------------------------------ ----------------------- ---- -- ------ ---------------------------------------------------------------------- ------------ - Final Inspection by: ----------- � ... ------------------ ----------------------------------------- _ __ - - ----------------------------------•------Date - - _ SA JOAQUIN LOCAL HEALTH DISTRICT E. H. 9'"� .I='68-Rev.