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- FOR OFFICE USE: A t ATIION PERMIT_ APPLICATION x 7- �7 -----------*�-`-`-=--"--------------------------------- (Complete in.Tnpli �: ..,. � Permit No. - \------------------------------------- -� .ri V 1 �f -6 —,73 _� F. lT Date Issued - - ------------- ----: -------------------------- ------------- This Permit` xpires�l Year From Diate Issued f a 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: ------ { i ) JOBiADDRESS/LOCA? N i '- CENSUS TRACT ` .c , � Id✓ I- l {' Phone Name ' Address ---------- --------- ----------------------------------------------- = _ city - ----- ---------------------- ---------- ----------- ------------------- ------ }--- Contractor's Name ---------- �'I�------------------------------------------- = License # --�- Phone Installation will serve: Residence ❑ Apartment Ho se' Commercial ❑Trailer Court ;❑ ! Motel b Other �----_, - , 7"-'-` ------------ Number --- ----- g /1 ":'-Garrg t r ---------`.1- Lot Size ,�c�r.?,x� ----------------- 1 of living units:._---_---- Number of bedrooms';_ - --_-_-- Eia a Grit 9 t { w � Water Supply: Public System and name ------------- i --- :__� __-_-: _-+ - Private( � 4 ----------------• ------ --- F----- - =-`-- - -- -- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat (] San dy Loam ❑ Clay Loam ❑ '. f Hardpan ❑ Adobe Fill'N4ater..ial _:_ {f-yes,..type--------------------_------- (Plot plan, showing size of lot, location of system in-,relation to wells, buildings, etc. must be placed on reverse side.) W I,- I NEW INSTALLATION: (No septic tank or seep pit permitted if public sewer is available within 200 feet,) i PACKAGE TREATMENT [ ] SEPTIC TANK;[ 4;.A• Size----------------------------- ------------ Liquid Depth, .-._----------_--:_-.:__- Capacity 3-k494------- Typ /-,609;--_------- Materia l:^!--------------- No. Compartments -----2-------:...... .- istance to nearest: Well -J✓OIVjL---------------------Foundation -1-.--__------------ Prop. Line __-_._.__-_.�---_:__- LEACHING LINE [✓JlNo. of Lines ------/-_______-__-_- Length,of each line-------4!�--------- Total Length ---- ........ 'D' Box ed_-__ iFype Filter Mdierial Depth Filter Material -----------------------. r-------------- ID Well.___v�ir _----.--_ Foundation --.- �l �.--________ Property Line ---- _-_.------. j SEEPAGE PIT � Depth --------- Diameter Number ------A/ Rock Filled Yes 0---�No .[ Water Table Depth ----------- Rock Size ----- ------Distance to nearest: Well ....... --------------------Foundation /�V------_---- Prop. Line ._..-__-___-_-_-___-: REPAIR/ADDITION(Prev. Sanitation Permit.# ------------------- ----------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ----------------------------- - ---------------------------------------------(------------------------------------------ ----------- DisposField (Specify Requirements) -_-----� - ----_- �- - ----- ------------- C/ e ' (Draw existing and required addition on reverse side) t 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 Workman's Compensatioi laws of California." t - I ` Signer -"Y-------------- Owner.�___y__ --------- _ tTitle ----------------------------------- ------------------ (If other than owner) FW DEPARTMENT USE ONLY J , L APPLICATION ACCEPTED BY ------------ - --"- ---------------------------------------------- DATE ----------,-_"`/-----"BUILDING PERMIT ISSUED ----------------------------------------------------------------- -------DATE ----------------------------------------•-- ADDITIONALCOMMENTS -------------------------------- -------------------------------------- ----------- ------------- ------ ---------- --------=--------------------------- ---------------------------------------------------------------------------------------------------------------------------- ------------------------------- ----------------------------------- ------ ------------------ -------------- ----------------•------------------------------ ------------ -----=------- :------ ------------------------------------- ;= --------------- --------------------------------------- ' ---- Final Inspection b _ ---------------- ---- -----------------------------------Date ---- � p y: ------------------- - — --- - --' SAN JOAQUIN LOCAL. HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M