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FOR OFFICE USE: __APPLICATION FOR SANTAfiF1FRMIT ----------------------------------------------------- Permit No. 7- .. �� (Complete in Triplicate) This Permit Expires 1 Year From Date Issued ---------=----------------------------------------------- Date Issued --------------------------------------------------------- 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: JOB ADDRESS/LOCATION .___________________________________„ ----If1)-------------------CENSUS TRACT .-___-__--__...._... Owner's Name ----- /4X14Vr 4AA1---------- --------------- ------- -------- ------------------ ----------------._Phone 4=........ ----- Address ---------- -----------j' �-�---�-� �7�-A-1VI' "-----------------------------•--. City ------T�/--��-�--• - -----------------------------------------•-•---- Contractor's Name .._____________---__________._-_-_ -___.-License # .•'_._?_.1'ke-:Z_ Phone _ -�� --._ Installation will serve: Residence g Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other -------------------------------------------- ff Number of living units:-----/__-_ Number of bedrooms __-/------Garbage Grinder ------------ Lot Size ---L«' ____'�._. � ........... ..—AP 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'X Fill Material ------------ If yes,type ________________________--- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) VV NEW INSTALLATION: (No septic tank or seepage pit permitted if public se available available within 200 feet,) PACKAGE TREATMENT SEPTIC TANKfLiquid Depth ----- ........ �r 7 Capacity l " Type �i'd-Ejq"5-! Material__-__-______________ No. Compartments ----�-..---:---- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. line ----------4.._._.----- LEACHING LINE [ ] No. of Lines ---- ----------- Length of each line------0C-------------- Total Length ,_ `C '............. f� 'D' Box .__/t------- Type Filter Material Depth Filter Material __1 `____-------------____............ Distance to nearest: Well _______________________ Foundation ------------------------ Property Line ........................ SEEPAGE PIT [ ] Depth -______:--___-_ Diameter ________________ Number ---------------------------- Rock Filled Yes No i❑ Water Table Depth ------------------------------------------------Rock Size Distance to nearest: Well ____________________________•----- ----Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _.__-..-___________-----_-.--_____) SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------...--------------------------- Disposal Field (Specify Requirements) __--_______ _______________________________________ ----------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ----•--------------------------------------------- ----------------------------------------------------------•--------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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, 1 shall not employ any person in such manner as to become subject Wm ' Compensation laws of California." Signed--------^1 - ��-_------------------------------------------------------ Owner BY ---------------------------------------------------------------- ------------------------------------- Title ----------------------------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- ----------------------------------------------------------------------------------------. DATE ------------------ ----------------- BUILDINGPERMIT ISSUED -------------------------------------------------------------------------------------------------- -------DATE ------------------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------- ------------------------------------------------------------------------------------------------- -------------------------------------------------------------- ------------------------------------------------------------------------------------------- ----------------------------------------------- --------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ -------------------------------------------------------------------------------------------------- -------------------------- -- - -- ------------- FinalInspection by; ---------------•----------- ---------------------------------- -------------Date --- A. ------------------- SAN --3 - --------.-..------- SAN JOAQUIN LOC L ALTH DISTRICT E. H. 9 1-'68 Rev. 5M ��