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FOR OFFICE USE: ��r �� 1 R APPLICATION FOR S' PERMIT ------------------------------------------------ (Complete in Triplicate) Permit No. - -------- --- ----_- 7C This Permit Expires 1 Year From Date Issued Date Issued IF/0-,1/ 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: JOB ADDRESS/LOCATION1 " _ V ----------------- --------------- -------------—�- ---------CENSUS TRACT - - - ----------------•- Owner's Name --------------C� -� Q- Address ------------------------ - - f " � - Phone - 6 d-1 1>-------------------------------- City - Ld - -- Contractor's Name ------------ lj S_ {--- 5 �/ - � ------------License # - - ------ Phone Y Q.-- -- � Installation -- will serve: Residence Apartment House❑ Commercial []Trailer Court ;❑ Motel ❑Other Number of living units:------- _--- Number of bedrooms ___''Garbage Grinder ------------ Lot Size Water Supply; Public System and name ________________ ______ __ " ---Private ---- ---- --•------------------ Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay Clay [❑ Peat Sandy Loam ❑ Clay Loam`s Hardpan ❑ Adobe'FR�, Fill Material ------------ if yes, type --------------------------"-- (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: 1No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANKX Size ------ Liquid Depth _-�--------------- TV Capacity 1 _ "-- ---_ Type - --. _-- _ -- - Material_ � No. Compartments _" ............. Distance to nearest: Well -_----___--- _� ' �-------------Foundation ------ �----�------ Prop. Line .-Z----•----•-•---- � LEACHING LINE No. of Lines -------/-------------- Length of each line-------- "AP'Total Length "_" ---•- 'D' Box ------ Type Filter Material ------"Depth Filter Material ----��-f---"-. Distance to nearest. Well --_--"" �d f f"-___""" property Line ,�! 11 SEEPAGE w - Foundation --- 1r- ------------------ SEEPAGE PIT Depth ___"-7�-------- Diameter _" 3 Number -------- --------- ____"" Rock Filled Yes No i❑ Water Table Depth ------------------------------------------------Rock Size / �� Distance to nearest: Well --------I . I A* _U_)------------------ Foundation ---I-A---it---- Prop. Line --_�.__-_-.-•. REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------- _--- Date ------•-.•-----•-"-- ) Septic Tank (Specify Requirements) --- Field (Specify Requirements) -_----__-_-" hereby certify that 1 have prepared this application and that the - -""-----_"--- -"""-"- ------------------------------------------------------- (Draw - ---------------------------- - ------- -ad ---------------------------------- ----------------------- raw existing and required addition on reverse side) y y e 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 Compensation laws of California." Signed ---- ---------- ------------ ----------- Owner --------- -------- - --------------------------- BY o er t n owner)-- ---------------------------------- Title -----X-'. lF + -- --- ------------------------------------- ------------ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY O S BUILDIP . - ------------------------------------ DATE ------- ""-- ----- ---------------------- ING ISSUED "-- -- - - -------------------------------------------•---------------------------------------DATE ------------- AD . TIONAL COMMENTS - - - -___""----= - --- ------- - - -- - -- ------- t.ei -- ------------------------------ - - ---'� - ----- ----- Final Inspection b - --------- ------------ -----•------- ----- ------ ---- --------------- ------Date ---W- -- - --- n�-------------- SAN - `SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M c f�