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FOR OFFICE USE o ��, _ APPLICATION FORSAN17A lON� P,ERNIIT ; t s�1Ler �P 1-�rriit}N o '---- ---- --- _.___-- i -(Complete in Tri lic�atel - p r - -----------0. . __..__- Date Issued � -l�- 710 M1 - This;,Permit'Expifes 1 Year From-Date Issued P Appl catt Zis hereby made to the San Joaquin Local Health District for a permit #o construct and install the work herein described. THN,--application is made in co pliance with County Ordinance N' i 549 and existing Rules and Regulations: i 9 - JOB ADDRESS/LOCA710N -----------------CENSUS TRACT -------------------------- A I --Phone Own er's Name 2!---e 'v i Address .--4 .140.? � C.� /moo ' - Cly " _ License' Cantr�ctor's-Name�- ._ �- --- - � - ��------ -------- ---- rt Pho e0_ � Instai,lation will serve: Residence ❑ Apartment House Commercial WTrailer Court '❑ y i Motel ❑Other ------------------------------- --.r�I do Of e Numb ------- er of living uni#s:_�'--.- Number of1bedrooms _�--__Garbage Gander /�fQ-- Lot Size _.d�-_�---�-------- , t ------Private Water Supply: Public System and name -- ----- i El r Character of soil to a depth of 3 feet: Sand'[:] Silt❑ Clay ❑ Peau❑ Sandy Loam ❑ Glfiy,Loam Hardpan ❑ Adabe Fill Materiafli_._-------_ If yes, type -------- ---------- �f Y (Plot plan, showing size of lot, location of system in relation to wells.'uildings, etc. must be pled on reverse side.} NEW INSTALLATION: (No septic, tank or seepage pit permitted f public sewer is available within 200 feet,} SEPTIC TANK: --- Li PACKAGE TREATMENT { ] I [ ] Size--------------- 1-? ----------- quid 1D'epth -------------------------- ---- Material- ----------------- No. Compartments ------ ------_-- ---- Ca Capacity - Type ` P I Distance to nearest: Well -----------------------------------I Foundation ---------------------- Prop. Line __._-__-_____:--- 4 Total Len th I LEACHING LINE [ ] No. of Lines -------- -------------- Length of each line'-- ------ g i 'D' Box }------- - Type Filter Material -------I(Mpth Filter Materia! ------------------------------------- #---- fV t f' =.. Foundation... = ----- Property Line ------------- Distance to nearest: Well ---------------------- � No . Depth Rock Filled Yes ❑ SEEPAGE PIT � ' � Diameter Number ---------------------------- Writer Table Depth --------------------Rock Size ----------------- •---- ' - i ------ --- iFoundation ----------------- -- Prop. Line --------- REPAIR/ADDITION ------- `= Distance1'o nearest:�Well _________________----------------------- # R' -------------- Date ------------------ --------- } � REPAIR/ADDITION(Prev.reySanitation Permit# --------------------------- - � Septic Tank (Specify'Requirem'nts ! ----------------------- � ` G rl� Disposal Field (Specif Re uirements] ! ' � Y q --------------------- # ��- 4 j �-- --r ------- - ----------------------------- - - ----- ------------- I a (Draw existing and required addition on reverse side) ,, I herehy certify that 1 have prepared this application and.,th.at the work will be done in accordance with San Joaquin County Ordinances, State Lows, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature cert f�'es the following: `"-" i "I certify that in the performance of the work for which t his permit is issued, I shall not employ any person in such manner t� -,. .........-�-�I as to become subject to 4rrkm an's Compensation laws of California: ' ?than Owner Signed - --- --------- -- --=-- -- ------ r• Title ----- --- -`�-"----- ----- ---- ---------------------- BY --{If owner FOR-DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - :I------ - ------------------------- -------- -- - -------- DATE - 7 BUILDING PERMIT ISSUED --------7------------------------------------------ = f DATE ------------------------------- ----------- ADDIT,IONAL COMMENi.. ------ - -----`----------------------------------- - ---------------- ------------ ------------- --------- -------------- .------- ---- ----- .--------- � _- - -- ---- - - ---- -------------- -- -------------------------------- -- - --- ------ --- - -- - _______ -- --_-- -,Date ----- Final Ins ection b ------------------------------------------ SAN ----------- --------------------------•. SAN AQUIN LOCAL HEALTH`DISTRICT CH. 9 1-'68 Rev. 5M. T _