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FOR.OFFICE USE: <br /> y2 l l APPLICATION WR'* ON PERMIT <br /> - _ P(Complete in Triplicate) Permit No, ____------------------ <br /> ---------=----------------------------------------------- <br /> __________________________ This Permit Expires 1 Year From Date Issued Date Issued .` : <br /> Application is hereby made to the San Joaquin Local Health District for c permit to construct and install the work herein <br /> described. This application is <br /> made in compliance with County Ordin'a1nc No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --------------- --- p--------------O =I-- -----------------------------CENSUS TRACT ------ .............. <br /> Owner's Name -------------- 6 n-----d----d A v'Co---------_----- ---------------------­-----I-------------------Phone �3�---19 to <br /> -------------------------------------------------------------------------------- - --. City __I/Z/C 1--------------------------------------------- ----------- <br /> Contractor's Name -------------------QaxN -----------------------------------------------License # --------- -------------- Phone ------------------------------ <br /> Installation will serve: Residence [3-A-partment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other --------------------------------- ---------- <br /> Number <br /> --------Number of living units:__________ Number of bedrooms ------e_....Garbage G inder Lot Size ______5-0___x160____-............... <br /> Water Supply: Public System and name ----------- ------------- -------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Pec t❑ Sandy Loam ❑ Clay Loam ❑ �' <br /> Hardpan ❑ Adobe [Fill Materi I ------------ 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: (No septic tank or seepage pit permitted if publi sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [SEPTIC TANK[ ] n Size---------l®__ ?�6_''__ _.___________ Liquid Depth ...._� .............. Q <br /> Capacity l00P - Type lDEgr _-____-- Materia ___/u11JC _(`_______ No. Compartments .... .............. <br /> Distance to nearest: Well -----i'_r�- ..................... _______________ Prop. Line _s�cP........_ <br /> - ---------------- Foundation 10 <br /> -- -- ------ <br /> LEACHING LINE [ ] No. of Lines _____1_____________ Length of each lin ----------CID Total Length ----�,_.O------------------ r <br /> 'D' Box ___-------- Type Filter Material..-_jk!;r----- Depth Filter Material ----12-- --- ---------I............. N <br /> Distance to nearest: Well ---lj��-------- Founda ion -------1b____________ Property Line ............... 0 <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number _______________________ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ---------------------------------------------- Rock Size ------------ -_-----_-------- <br /> Distance to nearest: Well _____________________________________ Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ____.....-_.._.___.. ....... <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ------------_--------- --.<.--------------------------- <br /> DisposalField (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------•----------- <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 Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local 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 Workman's Compensation laws of California." <br /> Sign �DOwner <br /> r----- -------- ------------- ------------------- <br /> BY ----r_- t<- = --- l/-�,' --------------------------------------- Title -- <br /> (If other than owner) <br /> FOR DEP N 014Y <br /> APPLICATION ACCEPTED BY ------------------------------- ----- -------- -- ------------------ DATE ----c�'_17---Z/----------------- <br /> BUILDING PERMIT ISSUED ----------- ------------------ ------- - ------------------------DATE -------------------- <br /> ADDITIONAL COMMENTS ---------- ----------------------------------------------------------------------------- <br /> ---------------- ------------------------------------------------------------------------------------------------------- -- ------------------------------------------------------------- <br /> - - 2 ----- <br /> - - ------ - ----- <br /> ----- ---- <br /> Final Inspection b Date _____ <br /> P Y ------ <br /> SAN JOAQUIN LOCAL HEALTH D TRICT <br /> E. H. 9 1-'68 Rev. 5M <br />