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FOR OFFICE USE: AP�I.AATIO AN TI I? IT ` ' 4R ' ,.a q --------------------------------------------------------- Permit No. ----- 1-1_Y. (Complete in Triplicate) Date --------------------------------------------------------- This Permit Expires 1 Year From bate Issued ' Application is hereby made to the San Joaquin Local Health District for a per to construct and install theywork herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - --- a---CaY_-6____-__. --> !�_11`- -='.� - - ==-=CENSUS TRrACT.,- - `-. --------• 77 V1,',V+vner's Name -------- -------- ------:- ------Phone .�-'---------•-`•1--- Address ----- / 1�, `€ �� --------------------------- Cityt¢------------=------- ------'.......-- P.Cor octor's Name ; •, a ��ry� >��w License # L_ -_ Phone '_ _S- Installation}will serve: Residence N Apartment House❑ Commercial :❑Trailer Court ',❑ Motel ❑Other --------- ------------------------------------- Number ------- A c kms. Number of, living units:....... Number of bedrooms __ _: -----Garbage Grinder -------.-- Lot Size _-_ _ __ „�.��,;�.,.,,,_..:.-----:_ Water Supply: Public System.'.6nd name ---------------------- -----------------------------------------------------------------=-----------------Private v Character of soil to a depth of 3 feet: SandSilt E Clay E] Peat E-] Sandy Loam ❑ Clay Loam b Hardpan Adobe ❑ Fill Material __ ___ If yes, type ------------------------- (Plot _-_- __----------(Plot plan, showing, size of lot, location of systemf in relation,rto',wells,buildi67gs,--etc.--must be placed on:reverseside.) NEW INSTALLATION: (No septic tank or seepage pit permute if public sewer-is`a a la le within 200 feet,)'` . i PACKAGE TREATMENT [ ] SEPTIC TANK'[J" Size_____----------------------------------- ------ Liquid Depth Capacity ----------- --- Type _____________--- ---- Material._.:_-_,_ --:;-_- -No." Compartments- -----.•-----.---_---- Distance to-"nearest: Well ___________ --------- Foundalia'_ -------------------- Prop. Line ______________________ LEACHING LINE [ j No—of'Lines ------------------------ Lengt of each line------------------- - ------ Total Length -----------.----- D' Box ------ Type Filter Mat --------------------Depth Filte Material --------------------.----------------.----.- Distance to nearest: Well ______________ _________ Foundation _______- ____________ Property_Line.7---____- __-_-___ SEEPAGE PIT [ ] Depth __-________________ Diameter ---- ----------- Number __.____.____ _____________ Rock Filled Yes ❑ No ❑ Water Table Depth --------------------- --------------------------Rock Size ------------------------------- Distance to nearest: Well _________ _______________________Foundati n -------------------- Prop. Line ....................... REPAIR/ADDITION(Prev. Sanitation Perm�ilt# -----___--_______ ________________________ Date _____ __--___-________-________ Pt (Specify Requirements) --------------------------------------------------------------- ) � ------------- 2-------- 716L -_-DisPoss! FeI (Specify Requirements) r r __ . : = Sq-------f-T-•_ --- -- --- D (b � raw existing an 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 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, I shall not employ any person in such manner as to become subject to Workm 's Compensation laws of California." I I' Signed --- ------- ----- ---- --------------------. Owner IBY ------ --- -- --- -- Title ------- - --------- (I other t an.o ned ,T - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _77-T-41-i-0-------------------------------------- ------------------------------------ DATE ' --7 ----- BUILDING PERMIT ISSUED -------------- - ------ ---------- ---------------------------- -----------------=•-----•--------------DATE ADDITIONAL COMMENTS - -- --------------------------------------- ---------------- r------------------------------------------------ ----------------- ------ _ - .- t'_ - ------------------------------------------- ' ------- -- - -- 7 IT ------------------------------------a --- - ------ --- --------- -------------------------------------------------- Final Inspec'tie X; ...- - - --- ----- - -- ----- --- ----------------------Date en - ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E tN: 9 1-'68 Rev. 5M