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FSR OFFICE U51: APPILICATiaN FOIE$ SAIVITA 1111. . + BION PERMIT ° o Permit NO. ...7� {Complete In Triplicate) ::.a: .. r -....................................................... i. Date Issued ......._....•_-•................................. This Permit Expires 1 Year From 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: jl JOB ADDRI: .E, ssflo TION ...... 5 � ��/.l.C�(�.r�,c......AIOG.......t00.J...CENSUS TRACT .......................:.. ,( pp Owner's Name .. ,f! _.__ .1 /[f, Lia .. ............................................ .....:............... eQ.9./? Q -^� Phone Address ...C� �s.1.._. �/ --.�-. .�. :-------••------- ...................:Cif) ...41;r .Cl .tel /. I �k 1111. _ ._ ......... ------ Contractor's Name License # ........................ Phone ....I Installation will serve: Residence PApartment Houseo Commercial:❑Trailer Court 0 Motel ❑Other............................................I Number of living units------ Number of bedrooms _,_.1a ,. ..Garbaga Grinder ............ Lot Size ............................................ Water Supply: Public System and name ........------------------..................................................................................Private ( Character of sail to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam I Clay Loam ❑ € Hardpan ❑ Adobe❑ 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.) NEW INSTALCATION. (No septic tank or seepage pit permitted'if public sewer is available within 200 feet,) Ei PACKAGE TREATMENT ;( } SEPTIC TAMC 'is Size_. .. :._.� .�._.::....... Liquid Depth ...�!_U. f�' Capacity 10.00_..._ Type CONG._ Material_- V-Y7VZ7.-. No. Compartments Distance.to nearest: Well ---------------:.l:.0:..... .....Foundation 1111... _.... . Prop. Line ................... _.kill LEACHING EINE [ } No. of lines -------�............. Length of ach 11rie--_._... t ........._... Total Length .__._ ..f .__-••�- f 1 �j 'D' Sox ! Type Filter Materiel ..17P._��1....Depth Filter Material /�.'1. 1I _..... _... ii Y ' f -- Distance to nearest: Well .. 7_�.__. .��oundation _ 1111_. Property Line `+.. ' �p SEEPAGE PIT [ ( Depth ...1.a.......... Diameter ...... Rock Filled Yes Ef Na y'11 Water Table Depth ... _...--••............................•Rock Size ._•�._�__.__........_.._.... h I , Distance,to nearest: Well -------!. ..........................Foundation _........_.......— Prop. Line .... I � • ra�. REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- -------- Date .-•............................... ) SepticTank (Specify Requirements) ----------------------------------•----------••---•--..•..................-------- ........................................................!_ 3 DisposalField (Specify Requirements) --------------............................•--••---------------------.._._.__....__....-•-------------------...------1111-------11141.. -- _. ' it .-. - - ......................I...................... .i ---------- ------------- -•--- --------•---•---- ------------••-•-•---- -------------------•-------------_------------------------1-11 1111.. (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 tocol Health,District. Home owner or Iicerr sed agents signature certifies the following: E "I certify that in the performance of the work for which this permit is Issued, t shall not employ any person in such manner as to becom su (ect to Workm . 's Co pensation laws of California." ° s Signed _.� - - -----•------------•--•-••- ------ Owner - �4 By ..------------------------- ------------------- -- _ -----------------------•----•-• - -------- Title ---•............ ----•-•-• T (If other than owner) FOR PEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..-- t ---------•-•----•-•-------------- ------11._1...1.. DATE -... .: ' .`3 !'�......._....... BUILDINGPERMIT ISSUED ---- ---------- --------------------------------------------------------------- ..........................DATE .......................................... ADDITIONAL COMMENTS .-_...-_-_1!11___1_.-. •-------- •-•-- F . ..................................................................... .......................................1111.._1_11__1..__._1111___ _ - ------------------------ ------------ ..............11_11_._.i. _____________--------------_------------------_ _ '_ _ - Final Inspection b . �---------- - ------------------------------------------------------ ------ ---------------- -------------------- -•----------------------------------- --------...--- ---•-------- .�..._- _ ....�............................_.__...----------•.._ 1111.--••----111.1.----------- ..---1111 p y: ---------------- �� ...................... Date Date ..�....._ �— �_....._....s. 13 2 -68 Item 5hSAN JOAQUIN LOCAL HEARTH DISTRICT 8/711 3M