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FOR OFFICE USE: <br /> APPLICATION FO NITATION PERMIT <br /> ------------------------------------- ------- Permit <br /> 7komplete in Triplicatel. _ <br /> .- =3 <br /> •----------------------------------------------- yy <br /> -------------------- -------------------- I This permit Expires 1 Year From Date Issued Date Issued -1-l"---d <br /> Application is hereby made-to-the San-JoaquinAocaI-Health-Distr--ict..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: r <br /> � l <br /> JOB ADDRESS/LOCATION -__ -ti�-��-.-,-.- ----------- CENSUS TRACT <br /> Owner's Name 2-V✓%/l.�J Gy' �r/-jYLS'--------------------------------------------------- -----Phone ------------------------------------ ] <br /> `,t L <br /> Address ---- /lop �k 2�.` %t+ City x'10I <br /> # l E <br /> Contractor's Name .--- f --------------------- ------------------------------------License # -------- ------------.- Phone --------------- -------------- <br /> 4 y <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living;units-.-../----- Number of bedrooms ------- Grinder _.---------- Lot Size ---------------- <br /> Water Supply: Public System and name ---------------------------------------------------------------------- -----------------4-------F-------------Private ®— <br /> Character of soil to a depth of 3 feet! Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam,1] ' <br /> i <br /> I Hardpan ❑ Adobe '❑ Fill Material _____________If yes,type s--------__.-__--_-----_--- <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: (No septic flank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I ] SEPTIC TANK f I Size---------------------------F----_...------------ Liquid Depth ---------------------._---. k <br /> ICapacity ---+--------- ------ Type -------------------- Material----------=----------- No. Compartments <br /> Distance to nearest: Well ------------------------------------Foundation ----------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line--------------_____..._____ Total Length ------------.---_-_-_-_---__- <br /> ` 'D' Box ---- ------ Type Filter Material --------------------Depth :Filter Material ---i---------------- ----------------------- <br /> �Distance to nearest: Well ------------------------ Foundation -----.__.--------------- Property Line i <br /> SEEPAGE PIT I ]j Depth.-' _''=_ -_.___------Diameter '(%7t ---_-_= Number ------ --- .--_--_---- Rock Filled Yes ❑ Na i❑ <br /> Water Toble_D.epth-------------- --------------------------..--- -_-Rock Siz� -� — ------ <br /> I <br /> Distance to nearest: Well --------------------'-------------------Foundation, --------- Prop. Line ----------------____-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------=---------------- Date =----=----------------------- ---) <br /> " � ..,, r E. <br /> Septic Tank {Specify Requirements] f --------- <br /> ---' --- - C/:" <br /> _ 4 I J � <br /> Disp of Field (Specify Requirements] � � <br /> „ r-e �� �, ,t� �� ��•. --------------------------------- -------------------------------------------------------------------------- ------------------------ <br /> ---------------- <br /> ,t , <br /> - _____.__._____.____________..-___._____________________.-_.________.___________.._________.__-..____-_ <br /> ---------- ------------ ---.--__--.-------------_._-.._ ..__-.________-------_ <br /> 1 <br /> y (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 Joaquin <br /> County Ordinances, State Laws,,and Rules and Regulations of the San,JoaquinLocal Health District. Home owner or licen- <br /> sed agents signature certifies the.following: <br /> "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 Work n' _Compensation laws of California." F t <br /> Signed -- -- ------------------------------------------- Owner F <br /> I <br /> By ------------- --------------- -------------------------- ---- -------- -------------------------------- Title --------------- ---- -- --------------------=-------------- ------------ <br /> (If other than owner) i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ►�- DATE _ _$ /� ------ t <br /> -- <br /> BUILDING PERMIT ISSUED ----------=-=-I-------`--------=-------------------------------------- =--------=--------- =--=----------DATE I <br /> ADDITIONALCOMMENTS ------------------ ----------------- -------------------------------------------------- -------------------------------------------=----------I---------------- <br /> --------------------------------------------------------- ------------------------------------ ---------------------------------------------------------------------------------- <br /> -== <br /> -------------------------------------------------------------------------------------------------------------------•--------------------- - - ------------------- ------•---------- --------------- <br /> --- --------------------------------------------- <br /> Final Inspection b Date .... -'^J- -- --------------------- <br /> p y- ----------------- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />