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FOR OFFICE USE: APPLICATION FOR PERMIT Permit No. "--------- -�`-'------ --------------------------------- + [Complete in Triplicate) ( / '' # ---------------------------------- Date Issued This Permit Expires 1 Year From Date Issued ----------------------------------------- Application; is hereby made #o the San Joaquin Local Health District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance Na. 549 and existing Rules and Regulations: , ,l.! ----- CENSUS!TRACT -------------------------- JOB ADDRESS/LOCATION _: U f-,-"��- ---f' - - ------- Owner's Ndme `•- #------- --------------------------------- 6 _ �f1�/ Phone------ City 4 - i _______.-_"______.__ I Address.,, 1 e h �4y ---- Contractor's Name � ��f i License 4 # :: � n Installation will serve: ,i Residence Apartment House❑ Commercial []Trailer Cour ❑ # _____--___- = Mote! Other --� Garbage Grinder Lot Size A � i ❑ Number ofliving units:---- Number of bedrooms ------- - Water Supply"Public'Systerrf and nano'__ __ __ - Private E] Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ 'Peat El Sandy Loam Q Clay Lodm>;[] �+ Hardpan ❑ Adobe, Fill Material ----- -_---- if yes,type - ---------------------^ of lot location of system in relation, fo wells,.buildings, etc. must be placed on reverse side.) (Plot plan, showing size �,, Y „-..,..-..� �. ,. NEW INSTALLATION: (No septic tank 'or seepage pit permitted if public sewer is available within 200 feet,) F Size--------------- -----------------••------------ Liquid Depth --------- -------------- PACKAGE TREATMENT € ] SEPTIC TANK'[ ] N ----__ No. Com artments -------------------•-- Capacity _ j- '---------- Type ------------------- Matena'i p !! ------------------------Foundation ---------------------- Prop. Line ---------------------- Distance to ne$rest: Wel[ __-________ I Length of each line--------------------- Total Length LEACHING LINE [ ] No. of Lines = - -------------------•-------- ' __t De th Filter Material --------------------------- ---------------- I It I Box .__�-"_____ Type Filter Material ___________"___-- i p ' __ Foundation ______ Property Line ----------------- o nearest: Wel! ❑ Distance t' f Rock Filled Yes No EQ SEEPAGE PIT [ ] � Depth `� i Diameter ----------- ---- Number --- -------------- Water Table Depth ------------------------------------------- ------- ----- _ Rock Size -------------------- , I 1 -----:Foundation ----- Prop. Line --------_------• -- Distance to nearest: Well ---_______--______ --------- - ' . 11 REPAIR/ADDITION(Prev. Sanitation Permit#__---------------- _- date ------------------ ] Septic Tank S ecif, Requirements) l - -----=----- --- - -------------------- ( P �Y q --- -- -------- ---- ---- ----------------------- - - 'l �---- - � - --�- ��-� -- ----- -------�--�•�'� -- Disposal Field (Specify Requirements) -__-- - / i" -----------------------------------------�-- � .� �, ` -------------------- *� ---------------------- ---------- --------------------------------------------------------- ------------------------- ------------------- -- - ----- l-------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and Ghat the work will be done in accordance with San Joaquin I Ordinances, State Laws, and Rules and Regulations of the .San Joaquin Local Health District. Home owner or Acen- Count Y ! f � . 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 suchmanner as to`become subject to Workman's Compensation laws of California." { ------ Owne + Signed --------- g Title _- . of er tho owner) FOR DEPARTMENT USE ONLY ti -- APPLICATION ACCEPTED BY --- ---------------•-- ---------------------- --------------------- DATE - - BUILDING PERMIT ISSUED ----- --- ----------------------------------------- ----- ADDITIONAL COMMENTS f ----------- -- - - - -" ------------------------------------ -------- ------ ----------------------------------------- - - - Date - -- Final Inspection by: SAN JOAQUIN LOCAL HEALTH DISTRICT -, C F u O 1-'68 Rev. 5M �� .�° ' �� %, .1 'x