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FOR OFFICE USE: V11-71p7 ryes "5e- /-v he a-;, 4r v a c�� ?� APPLIbATION FOR 54 -,xT10�1 P,ERJNIT i , 1'1a-S �V►�� "'° � v�- e � L� {C plete in r licate) r" -----------------------------------------_--------------- This Permit Expires ] Year From Date'Issued Date Issued Application is hereby made to tee cafHea tl i tZcct fora perh�it to constr and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and-Reguftrtions: JOB ADDRESS/LOCATION __ _CENSUS R CT __- --% --------------- ---------- -- ----------- - --- ---------------------- Owner's Name - ----- ----- - ----- Address --- -- n Pho e Address II f"_ '. , " ---------=--- City l r --- ---------- -=---License # .�c� hone;. b r� �� Contractor's Name --------_. -- _ -- r 9 ;.. Installation will serve: Residence ❑ Apartment House,E] Corzmerci. ❑Trailer Court;'l] jj Motel ❑ Other ----- Number of living units:------i_---- Number of bedrooms -7^___Garbage Grinder _----_- Lot Size -- ------------------------- --- Water Supply: Public System and name ----------------- -------------_-- - ---------------•-----Private Character of sail to a depth of 3 feet: SandE] Silt❑ CI ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material ------------ If yes, type _______15----------------- {Plot plan, showing size of lot, location of syste ' in relation to wells, buildings, etc, must be 'placed on reverse side.) }� NEW INSTALLATION: (No septic tank or see ge.pit permitted if pub;'c sewer is av iable within 200 feet;) PACKAGE TREATMENT [ ] SEPTIC TANK:[ Size_ yy ' X .- -----fk-�--------- -- -- -- Liquid Depth '____1/ .� Ca acity _O Type _ Material- Compartments _ ..�,._.____.. P Distance•to Weare Well __---�Q Foundation __ _� _--___ Pro Line __ _ o. ------------------ - LEACHING LINE [ No. of Lines-(----._r0 --------- --- LengtK-bf each line_____fa ______________ Total Length :_ffJO ............ 'D' Box . Type Filter Material____ _f�__,Depth Filter`Material ---__ -_!_____-----------Z------------ Distance __ nearest: Well -------- ---- .------- Foundation ,._�_a.__-_-_---- Property Line SEEPAGE PIT [ Depth .- -----I Diameter _3- ______ Number --------- p?l ---- -_ Rock Filaed Yes No Q r It . �. Water Table Depth . !J�- ' -------------------Rock Size 3------ - Distance to nearest: Well ____'_:_ _I-06)-------- ____�:a_-______- Prop. Line _.��_- ------ 1 REPAIR./ADDITION(Prev. Sanitation Permit# ------------ -- ---------1_- - -------------- Date ----------------------------------) Septic Tank (Specify Requirements) ----- --------------------------------------------------------.-----------------. •--------------------------- DisposalField (Specify Requirements) -------------- = ` --------------------------------------------------- --- ------------------------------------------------ ------------------------------- ,_ ------------------------------- -------- ------------------------------------------------------------------- ------------------------------------------------------------------------------------------- (Draw exiting and required addition on reverse side[ I hereby certify that I have prepared this application and that the work will be done in accordance with Sart 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 performancet, e work for which this;permit_is~issued, I shalt not employ any person in such manner I as to become subject to Workman s o pensation laws of if rnia." Signed -------------------------------------------- -- ----------------- ---- wrier 0 BY --_---+--- ----------- ----------- ------------------------------------ r (If other than owner) .0 _ FOR DEPARTMENT L1SE ONLY APPLICATION ACCEPTED BY -------------------------- - ---------------- ----------- DATE !1"a_Q'�OQ----------------- BUILDING PERMIT ISSUED --------------- ---------m------------------------------------- '------=-------- - - ----DATE --------_--•----------- - -- -------- -- ---------=------- ADDITIONAL COMMENTS --------------------------------------------------------------- - = --------------------------------- -- =- ----------- ----------------- - 7 - --- --- --------------------------------- -------------------------------------°-------------------------------------------------------------------------------------------------------------------- �. e -- Final Inspection by: ---------------------------•---------- ----- ------ --- --- _Date _ SAN JOAQUINI LOCAL` HEALTH_. DISTRICT E. H. 9 1-'68 Rev. 5M. �/ a