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FOR OFFICE USE: APPLICATION 1=0t�SAOATION PERMIT --- Permit No. (Complete in Triplicate) ----- "(I This Permit Expires 1 Year From Date Issued Date Issued _- �? _? O 2-(—V,41 01? 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: (.VLL(ftv til..+ rA-Er_7V A.[r_ "•`��CC�� OJOB ADDRESS/LOCATION ____ca5,__I___ � -_-- Hh - aje ---- CENSUS TRACT -------------- _-_ Owner's Name '-!_� Imo . ' !"► ,1 _ - --1`1 ----------- Phone4777-11 ' pp _, Address ►\ City - + ---- ------------------- ----- / y-------------------------- Contractor's Name -- -C�- ---------------------•---------.License # ----------------------- Phone - ------------------•--•--•-- Installation will serve: Residence)XApartment House❑ Commercial ❑Trailer Court ',❑ EMotel ❑ Other ------------------------------------------- Number of living units:__________ Number of bedrooms ____..Garbage Grinder __________ Lot Sized___--___L-' �______________ Water Supply: Public System and name ----------------------•-------------------------------------------------------------------------------•--------Private ❑ Character of soil to a depth of 3 feet: Sand'E] Silt❑ Gay [] Peat❑._ Sandy Loam ❑ Clay Loam ;❑ 1I Hardpan ❑ Adobe&, Fill Material --------- -- If yes, type ___________________________ r" ' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) p 1 seepage pit permitted if public sewer is available within 200 feet,) NEW INSTALLATION- (No septic tank or ,y PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] SizeJ(,v_0.0___} _ ------------ Liquid Depth ____,______________.____. Capacityfi�iQ�__ I pet" rte-( Material � -� No. Compartments _ ________- . Distance toI. nearest: Well ------------------------------------Foundation ----------------------- Prop. Line ---------------_------ LEACHING LINE [ ] No. of Lines_,________________ Length of each line-100-------------- Total Lenpth=,�___ --- I.....a0t 1 'D' Box 1 ----- Type Filter Materia I ___ ,t_Depth Filter Material - ________._.___._._ __ Distance to nearest: Well S1__ Foundation -------------- Property Line _.___ ................. - SEEPAGE PIT [ ) Depth __ ______ Diameter-__---__ Number ----------------- /-------__ Roc Filled Yes X No C3 Water Table Depth ------------------------------------------------Rock Size --�--------Z-_------------- Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line ----------_.__........ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ___________-________..._-.._....--) SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------- ------------------------- Disposal o'Field (Specify Requirements) ---------.---- ----- ---------------- ----- ----------------- -------------------------------------------------- ---------- ---------------------------------------------------------------------- -------------------------------------------- (Draw existing 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 San 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 ofithe work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed _ . ---(-1`fin � ^�-^2----- wner / Title (If other than owner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ ------ -- ------------------ DATE ' BUILDING PERMIT ISSUED = ---DATE -------------------------------------- --------------------------------------- --------- ADDITIONALCOMMENTS --- ---- --------------------------------------------------------------------------------------=--------------------------- Y __-------------------- ______________________ _ _____t+____________ ---------------- _______________--------------________________________. -____________ ----------------------------- _______________________________________ _____-____i___ _____ _ __.--A_____________.____.____- ___________________--_____-_______ _.________ Final Inspection by: Date ' ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M