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FOR OFFICE USE: APPLICATION FORNITA-TION REKNIT ---------------------------------------- Permit No: QComplete in Triplicate) -------------------- ----------- Date Issued _�-� ---_�l This Permit Expires 1 Year From Date Issued Application is hereby made to the an Joaquin Local-Health District,.for-a permit to construct and install the work herein with C" my Ordinance No. 549 and existing Rules and Regulations: described. This application is madelin compliance w q --------- JOB ADDRESS/LOCATION .-.----- -- -=/ --i�' � ------------ -- ---CENSUS TRACT ------------ - -- -------------- -----.Phone. ,��r Owner's Name ------- -- - --- - ----------- ---------------------------------- 61 2-01F �• . city ------------------------------------------- Address ------------------ - --- j _ # Sly Phone .+-`�l��+.a • Contractor_s Name--,, =• `P! -,.License _ F Installation will serve: Residence" Apartment House Commercial ❑Trailei Court•',0 Motel Other -------- ----------- 'G ------ Number of living units:--____�---- Number of bedrooms -�j------ _q age"Grinzler �Y Lot Size _-- •?--__- h--------•• t .. _-- _•,,... , ,.tom I ---Private ❑ Water Supply: Public System and name -____- -_---_ --- --------- �r ------ --- PP Y� Y • ,--•------------- ----- ,,,moi----.-,��:---�-•'----� Character of soil to a depth of 3 feet:. .5and'❑ Silt'Q Clay ❑ Peat;❑ "San D, ❑ 'Clay Loam'❑, 1 Lk ^ Hardpan El Adobe,, Fill Material ------------ If yes,type --- (Plottplan, showing size of lot, location of system in relation"ta wells, buildings, etc. must be placed on reverse side.) Q NEW INSTALLATION: .(No septics tank or seepage pit permitted if.public sewer is available within 200 feet,) - - -- Liquid Depth ___------------------- y PACKAGE TREATMENTCa P SEPTIC EPTICI: TANKt ----------- --------------- Siz.e--_------- -- --- MatNgCompartments, - -------------- ,. erial - ------- t--- Type Distance to nearest: Well ---------------------------- Foundatiori -__-_:--_---__-- ------ Prop. Line ------------••-------- '' , LEACHING LINE [ ] No. of Lines --------?:::---- - - Length of eachline___--_---' -- !-_`_ Total Length D' Box__--11_ Mateual -.___=------Depth Filter Material - . ! Foundation ,P,roperty Line Distance to nearest: We11 :_:_"_`_.________ -- # i 'Depth Nuns er._:I --------� Rock Filled Yes ❑ No i❑ SEEPAGjE,-PIT [ ] [ p - - Diameter -------------- - ,�,.. - ---------- --- -- iRock Size ------------------'"------------ 'Water 4- Tale Depth ------- ----------------------- 0 , .,® k -._...-.i. :Distance to nearest: Well --------------------- -------------- Foundation --------- ----------------------------------- - ----- ---- Prop. Line ---------- •---------- i Permit-# - ---------- Date = - -1 REPAIR/ADDITIONSeak (Specify cQfe Requirementon st i) --- --------_---------`------------- ----------------- I p P Y q -------- ----------------------------------------- Disposal Field (Specify—Require n r" --------- -------- �7 ----- ----- t -�---------------------------- --------------------------------- - - I ----------------------- (Draw - -------------- --------------------------- i --------- -------------- .a I (Draw existing and required addition on reverse-side) i I hereby certify that I have prepared this application and that 'the work will be doneti in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Locdl%Hedlth District. Home owner or licen- sed agents signature certifies the following: ) .. "I certify that_inihe,performance_of_.the_work-for which this-permit-is_issued,' 1 shall not employ any person in such manner as to become subject to Workman's Compensationaaws of California." [' F ' Owner F Signed fi --------------------------- -------------- By ------- --------------- - ----------- = • !' - ------------- Title --- - --------------------------------- ------------- (If other tha caner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ._� --------------------------- ------------- --------------------------------------------- DATE ] BUILDING PERMIT ISSUED -----------'-------- -------------- - -------- -------------DATE -------------•----------------------------- - ------------------------------- ADDITIONAL COMMENTS ---- ----------- -- ----------------------------------- ------------------ ------------ ------------------------------------------------------------------- - --------.. ------------------ ---------------------- f = -------------------------------- - ------ --------------------------------------- Fina! Inspection by. d -- ------------- ------------Date _�- �-- ---------- -------------------- --- -- - -- --------- - P i SAN IOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M _ _