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F`>R OFP'ICc USE: <br /> .dmICAVON FOR SANFYAnoO,, pnMff <br /> ....._ _._ ICornPleM In Triplicate) Permlt No. . <br /> . .. _. This ponelf Expires I Year From bw^ issued Dans Issued S..Z '1 <br /> .;..Appliwtlon is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein ° <br /> deKribed. This application is mea/de In mmpllonce with County Ordinance No 549 and existing Rules and Regulations, <br /> OB ADDRESSAOCATION ... 1Q.CL�S r.-:.. -__ SC� <br /> w! 9 --__. . - CENSUS TRACT . <br /> Owner's Name ..J11Pn/TE..... VA.. YD � , 'x... .... ...... <br /> .. Phono - ,.. ' <br /> Address .......� /, j,J..... - .. ULJ. — ......... .....:....... Gry <br /> f � „/ . . . . . . . . . ........._ .. .. <br /> Contractor's Name... dW41/7R. .:.:........ Llcenxs is ..... . .......... . Phone ................ . <br /> Installation will serve: Residence[?<Partment House❑ Commercial []Trailer Court, ] [ <br /> :. Motel❑Other ............... <br /> ,� ! A <br /> Character of P cola de ste of 3 d'umber of bedrooms . Gt '`age Grinder /LlQ Lot Size .�-cR€A ....... <br /> Nvmber of I:vin units-._. N <br /> Supply: System r :...Private�?-"- e'a' <br /> 8 <br /> ..... 1 ... <br /> P eN' Sand[] Sllt❑ Clay ❑ Peat❑� Sandy Loam Clay Loam ❑ t ' <br /> Hardpan[] Adobe' j' Fill Nateriol It yes,typo. �. ......._......._ <br /> (Plot plan, showing size of lot, location 'of system in relation to wells, buildings, etc. must be placed on reverse sldo) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> __.. . <br /> ;y PACKAGE TREATMENT [ I SEPTIC TANK f ]' Size.... . . . ..... ..... .:.... Liquid Depth ... .. <br /> Capacity ..__... ......... Typ ... .. ..... Material - ..... No. Compartments ....... ...... , <br /> Distance to nearest Wall .::....... ....... ...:..Foundation .. ...... Prop. Line.. . . <br /> -------- <br /> LEACHING <br /> LEACHING LINE ( ] Noi of Lines ._ . . ........ .Length of each line.._... ... ..... To}al. Length ....... ....... .. .... <br /> 'D' Box ..... Type Filte Moterial ....................Depth Filter ....Distanceto nearest: WellFoundation Property LineSEEPAGE PITDepth Rock Filled <br /> WaterTable Depth ........................ ........................................ ......... <br /> Date .....<... ...................... - <br /> Septic Tank (Specify Requirements) ..... . . ... . ... ..._........................._ ... .. . .. <br /> Disposal Field (Specify Requirements) . Xi:i 1./l.�E ��T /�!.... :. <br /> (Draw existing and required addition on rederse side) <br /> I hereby certify that I have prepared this application and that the work will he done in accordance •h Sen Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. H�..,e owner or Rcen- <br /> sad agents signature certifies the following: <br /> "I coni / J.b <br /> perfor an a P for ich This permit is issv�d:►shall not employ any parson In such manmras to b t to rkman' om safio aws of Califor7fi:'YSigned ( / <br /> �. <br /> B .. ..... r .,P.. Title .. .. .. :. ... ......i .......__..._.. <br /> W other than owner) ! s <br /> h FOR DEPARTMENT USE ONLY+ <br /> APPLICATION ACCEPTED BY *s+` - DATE .... 'l.._.�7 <br /> BUILDING PERMIT ISSUED ....._ _... ... ........ .. _ _. ... ...._.........DATE ..._ ... <br /> ADDITIONAL COMMENTS . _._ _. . -. _......_... _:• <br /> .. ._ ......_ . . . ....... ............................ .. <br /> .r ...-:.. - ... .. <br /> _... ...... ....... 11 <br /> Final Inspec (/f'./.. __. !I(///. . -_. . _ Date . . ' �� .../.., .., <br /> SAID JOAQUIN LOCAL {hr.ALTH DISTRICT / <br /> E. H. 9 1•'68 Rev. 5M C `/ <br />