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a r FOR OFFICE U5E: APPLIC ANITAT)ON PERMIT Permit No./.3Z?.�?7 ic._�mplete in Triplicate) ' ................................................. -DoteIssued/�?.:`..�.1 ......................................................... This Permit Expires i Year From Date i ubd 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: 67C J06 ADDRESS/LOC O O. C ......CENSUS TRACT .............. Owner's Name ....: :.... .......................... Pone ......... - - Address �. _ ,.r ........_.. City . �1'P ....---.._':.......-•.................••---........-- ....... �` ............... .......... . .. .............. I Contractor's Name-----... ��1. ------------------- - - License # ._......- _ Phone i Installation willts�rve: Residence partment House❑ Commercial ❑Trailer Court Li I i Motel ❑Other ............................................ ; Number of living units_____________ Number of bedrooms ............Garbage Grinder ............ Lot Size ._ ..l.F..49 / �I ` Water Supply: Public System and name ------------------------ .......•------•-•---•----------•••--•--•••-••-•----------•----•-- -----...__...._Private Character of soil to a depth of 3 feet: Sand❑ -Silt❑ Clay C] ' Peat❑ Sandy Loam ❑ ,Clay Loom k ; Hardpan ® Adobe'❑ Fill Material _.__. ...... If yes,type -------------_----------— (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be,placed on reverse side.) NEW INSTALLATION: {No septic tan.k.or. seepage pit permitted if public sewer is available within► 200 feet,) C PACKAGE TREATMENT [ ] SEPTIC TANK_ ] Size................•-__.____..---......... ........ Liquid Depth __....................... . t f Capacity ._...._.._........,. Type .................... Material.----...-------------- No. Compartments ...................... Distance to nearest: Well ........................... Foundation .................... Prop. Line ...................... LEACHING LINE [ ] No. of Lines ........................ Length of each line------------------.......... Total Length _.__...... ................. 'D' Box ............ Type Filter Material ....................Depth Filter Material ---..__ ................................ aDistance to nearest:'Wel) ........................ Foundation ......................1. Property Line ......................... SEEPAGE PIT ["]"` ' Depth ............:.......' Diameter Number ..--.----.------......------ Rock Filled Yes 0 - No ❑ Water Table Depth --------------- ..............`" .....-----.Rock Size ---- ............................ ¢Distance to nearest: Well ........................................Founcld ion..___...... '_ Prop. Line ..................... REPAIR/ADDITION(Prev. Sanitation Permit# .. ...... ............................... Date ................................... i Septic Tank (Specify Requirements) ....------- •• - •- - ..... � 1�. :.�...- ...................... Disposal Field (Specify Requirements) ---__-.--- ' i ----- 4 (Draw existing and required addition on reverse•side) 1 hereby certify that l 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 a performance of the work for which this permit is issued, I shall not employ any person In such manner as to becom su ct to rkm 's Compensation laws of California." ' I Signed .. _ t - ------. Owner BY .......................... ...... Title ........................................................................ if other than owner) 1 r� EOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .-•--------- --- ----- DATE -_g:. _'?.�f............._. BUILDING PERMIT ISSUED ... ---- ---=-------------------------------------•-••. •......_---..._........... DATE ..... ADDITIONALCOMMENTS -----•...........................................................•---.•._._....._...._.•......--------•---........................:........7--•----.. ------- r _ __ ........................... .. . ..�. •• C .__._. �..... .__. .'. .................. _ -.... ... _•......_.......T.__................. ._. ,.`..--...._ _.......... Final Inspection by: ............. �' . •�. Date .._ .s� C _''. _ . '...... -... ,SAN JO.AQUIN LOCAL HEALTH DISTRICT 7/,723 M -F 14 13 241_'68 Rev- 5M - - _