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FOR OFFICE USE: APPLICATION FO,R •SA ----------------------- PERMIT ----------------- (Complete P lete in Triplicate) Permit No. ------ ` This Permit Expires i Year From Date Issued Date Issued - �--3 -_?-7 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install r the work h described. This application is made in compliance with County Ordinance No. 549 and existing Rules andRegulations.rein JOB ADDRESS/LOCATION .- -- ------------CENSUS TRACT - S ---------------------------------------- ----------- --------------------------------------- Name - - _ 1 y,� ------ Address r------------------Phone57 1-° 0 l --'/�/vim , _--- _� p ------------------------------. city f !__ a Contractor's Name ---_-_- .-Jam- -----: -e------------------------------- #o"��ls �l - Phone Installation will serve: Residence ®Apartment House E] Commercial ;E]Trailer Court ;0 ' . I Motel ❑Other - - Number of living units: -- Number of bedrooms ------------Garbage Grinder ------------ Lot Size Water Supply: Public System and name _______ `---------•--•- pP Y� Character of soil to a depth of 3 feet: Sand Silt Clay -- ---------------------Priva a Private -p ❑ y ❑ Peat❑ Sandy Loam •E] Clay Loam Hardpan ❑ Adobe'E] Fill Material ---------- Ifes - Y , type ---------------------------- i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size------ --= --------- ---------------- --------- Liquid Depth -----------------•-------- Capacity ----------------- Type -------------------- M erial-------------- Na. Compartments - Distance to nearest: Well ----------------------- -----------Found ion ---------------------- Prop. Line ---------------------- LEACHING LINE [ I No. of Lines _--_---_- Length of ach line.-_-- _ -- ------- - - Total Length Box -__- ------ Type Type Filter Material -------------------- pth Filter Material ----_----_- Distance to,nearest: Well -------------- Found ion - Property Line ------------•- --------- SEEPAGE PIT - Diameter [ 1 Depth ------•------- Nu er -------------- • ----------- Rock Filled Yes ❑ No �- Water Table Depth --------------- ------------- ......... -------Rock Size Distance tonearest: Well ---_ -------- ---------Foundation Prop. Line ----------------•- -- REPAIR/ADDITION(Prev, Sanitation Permit# --------- -------------------------- Date -----------------) Septic Tank (Specify Requirements) -------------------- -------------------------------------------- ------------------------------------------------ ---------------- Disposal Field (Specify Requirements) --_ - -- -- ------- -------- /�� -------- ---------------------------- ------------------------- -------------------- -- dition- -- - - (Draw-existing and-required-adon-reverse side --- - - I hereby certify that. I have prepared this application and that the workwill 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: "L certify that in the performance of the work for which this permit is issu aed, I shall not employ s to become subject to Workman's Compensation laws of California." any person in such mangier Signed --- --- --- ----------------- -------- --------------------------- Owner (f other than owner) ------- Title `. APPLICATION ACCEPTED BY-_ FOR .DEPARTMENT USE ONLY _.�1-11`�---------------------------- •�_--_•--._.-_ . BUILDING PERMIT ISSUED ------------ -- 4-- '------ DATE _---- - -_-_"-- ----------- DATE -- -------- --------- ADDITIONAL COMMENTS -------- -- ---'- ------- - ------- -------------------- -�--------------- --------- - -- ------ -- --------- -------------------------- -- -------- ----------------- ------------------- ---- ---- ----------- - ------------------------------------------ --------------------------------- -- -- ------ - - ------------- -- - ---------------------- FinalInsp ------ ------- --- --------------------------------- z-- - ------- ---- --- -------- --:- - - - - -- - - -- - ---------- -.Date ..... ... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M `