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Ae'YLI1rAfIVN FOk SANI`tAYIfJN VtkiAii 7` _/yo <br /> (Complete In Triplicate) Permit No. .. ................. <br /> ............................................... .-. .... <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> 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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION NyWwy-,�; �.. .. .Y. - /.Y... !!c�G?. . Ci`. ....r........2 <br /> Owner's Name . ._.13.C.2 0 V_777.;..........13...rQ..%........d. `l3.-. r. 411G/!.1...1. d. ,•ENPhone RfiC�'f <br /> Address y0."/ ,_.. ./ ry. .2 P)4/llv)e.._.R.d...-----...... City ... vt. _i'N.13 .. . ................. ......... <br /> Contractor's Name . .. :r�x�! �n License # 1..4✓ .. ..... Phone .........../.. <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court O <br /> Motel ❑Other-MoGi.G HaM e- <br /> -.......... p <br /> Number of living-units:.... ...... Number of bedrooms .......Garbage Grinder ............ Lot Size ..R. . 4.(_!G <br /> A........................ <br /> Water Supply: Public System and name --------.........................._................------......._..........................................Private <br /> Character of soil to a depth of 3 feat: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ® Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ FII( 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: INo septic tank or seepage pit permitted if public sewer Is available within 200 feet,) <br /> PACKAGE T EATMENT [ ] SEPTIC TANK{ ] Size.-.-y,.!.-X...-�..7.................... Liquid Depth ....:.`�.�..'...............� <br /> Capacity �.ilObG-�[. lire (ro>7 C u c. .r <br /> rU _ - ...,.... Type ........ = Material... ...ir........ No. Compartments .....................V <br /> Distance to nearest: Well ....................................Foundation .....1�............ Prop. Line .#O,...........IAi <br /> LEACHING LINENo. of Lines F " <br /> [ 1 --.-�....-..._.....- Length of each line.......ryE.r............... Total Length ....�..ta.............. <br /> 'D' Box .-..�...... Type Filter Material .....Depth Filter Material ....AU " r <br /> Distance to nearest: Well ........................ Foundation Property Line ........................ <br /> SEEPAGE PIT [ ) Depth ----- ---------_--- Diameter ................ Number ------------...-_.._..... Rock Filled Yes ❑ No ❑�r <br /> Water Table Depth ..................... r <br /> - Rock Size ................ ............ r <br /> Distance to nearest: Well .............j-..............:.........Foundation ...........r........ Prop. Line ........--.........pr <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -..7.7GG ................... Date ...(...:. ..:.�j...-.... ) r <br /> Septic Tank (Specify Requirements) ..........�/.....>. . �.. 2z-'.7�............. _...........-..... ...... <br /> Disposal Field (Specify Requirements) .................................:....................................... ................-.......... ....-.._.................(J <br /> --- ------ ................ - ------------ ------- - ------------I--_----------------I...............I.........................................................................._......--- <br /> ... ..- - ---------- ..._.............._. . ...........------_----------- ---------...- ................................................... <br /> ---....... <br /> ...........-....... .... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa uln <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or cow <br /> sed agents signature certifies the following.- <br /> "I <br /> ollowing:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .L.' 14/(7"40ivr i S:cN <br /> .. --------. ...... ......... Owner �. <br /> By ., Kae. ... .... .. Title __ <br /> erst an owner) <br /> FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY ----- ..... --- ------........ .....I.... - .... ........... DATE .1�.7 .. ._..... ._..- <br /> BUILDING PERMIT ISSUED .------ - - - ...............__.....__..._... DATE .... ........... ...... <br /> ADDITIONAL COMMENTS ----- ........................ ...... - - ......._.... - <br /> ...._........ .................. ...................................................................... ................. .... .... ..... .. .......... .........-.. ......................... <br /> ......................... .- .- ....... . ............. ......... --- -.._.. ---- ......................... ....-._-...... ... .. ..._... .......... ...................... <br /> ................ _.............- -------- <br /> Finallnspectionby: .............-' ...---.--------............................... ............................Date .. .. . .7,(�......... <br /> EH 13 2La 1-68 Hev. 5f SAN JOAQUIN LOCAL HEALTH DISTRICT ©/7L 3M............ <br />