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FOR OFFICE L1SE. APPLICATION F9R S CITATION PERMIT Permit No. 9. c�- ..__. _._. 11 .......//.-__�3 p . .... .._............�--.... f*.,. ...7.. ...:Ia`..�.. ............................................. ...••-.__ (Come 4etef i Triplicate) ------------------- This Permit Expires 1 Year From Date Issued Date Issued -....2--.. Application is hereby made to the San Joaquin Local Health District for a per to construct-ar% `install. the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .. 1. (J� / . ! -'...................................I...........CENSUS TRACT .......................... Owner's Name ..... � . ..A .f.� � Phone Address _.._.._._�� ,..w �... F4/z?Zw-".-,.?..................................... City -1:91te ---......................................................_ Contractor's Name ......le. U..__/�lll� _____________________________________License Phone . Installation will serve: Residence AApartment House Commercial ❑Trailer Court OL Motel ❑Other ._..._•_•................................... Number of living units:.../------ Number of bedrooms ..,.....Garbage Grinder -fid... Lot Size ........... Water Supply: Public System and name ....... ......................................Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe R Fill Material __._... .... If yes,type .......................... (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK( ] Size................................................ liquid Depth .......................... Capacity .................... Type ---_.-__..._._. .... Material---•------__--_..... No. Compartments ........-.-.....•...... Distance to nearest: Well ____________________________ _.Foundation ...... ............... Prop. Line X7 LEACHING LINE [ ) No. of Lines ........................ Length of each line............................ Total Length ............................ 'D' Box __. -------- Type Filter Material ....................Depth Filter Material ......................................... 4.- Distance to nearest: Well ........................ Foundation .................... Property Line D SEEPAGE PIT [ ) Depth _ Diameter Number Rock Filled Yes ❑ No ❑IV Water Table Depth Rock Size :i Distance to nearest: Well ________________________________________Foundation ........---......... Prop. Line ......................f REPAIR/ADDITION(Prev. Sanitation Permit# ....•--------------•---•---._--------------. Date ______--_-_._____._.--_____---_-) Septic Tank (Specify Requirements) ................................. -- -------------- 01 ---•------ .... ;� - Disposal Field (Specify Requirements) .. 1.. ...... -_f! ___ �s.�,�< ___%, __..____ _"_. ....... ..................... .-_..........•-•---------- ......-------------------------------------------------------------------------------------........................ .............. .......................... (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 of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---- Owner By ..... ---`-----------------------------------•-•--_- Title .. .> .....L..................................... other than owner) l:0 'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- .. :. - - ..................-.................................... ©ATE 1-/1 .2 ..... ._..__.... BUILDING PERMIT ISSUED ....................... •--- -• - --- -----•--------•- ..........................................DATE --- ............... -•-•.......... ........ ADDITIONAL COMMENTS ............................. ----------------------------------•--------------- ......._.,Date -3_J.�'..._. .._.._ Final Inspection by: ...�.: ....................... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.1.3 24 1-'68 Rev. 5M 7/72 3 M