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FOR OFFICE"USE: ------------------------------------------------ *;)'S APPLICATION FO *;)'S PERMIT ---------1- -------------------------------------------- (Complete in Triplicate) Permit This Permit Expires I Year From Date Issued --------------------- ---------------------------------- I Date Issued A��7:-& 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 ADDRESSAOCATION Z-9-9---- 9-��- ---CENSUS TRACT f Owner's NorLie .--(---------- Address ------------------------------- ------- ----�4-0----------- ---Phone ---1-77-5- ------- - - - -- --------------------;-----------. city Contractor's Name rV----------- ............. -------.License # ------------------------ Phdne ------ Installation will serve: R,6sidenceXApartment HouseE] Commercial []Trailer Court Motel []Other Number of living units451`t- Number of bedroom$ ______Garbage Grinder -Lot Size --------I Water Supply: Public S ___.__-_________ystem and name .. ........ ------- --------------Private Character of soil to a depth of 3 feet.. Sand -Silt El Clay [I Peat E] Sandy Loam ❑ Clay loam F Hardpan El Adobe ❑El Fill Material ------------ If yes, type ______--_-`-____- 4 Y plan, showing size of lot, location of system An relation to wells, buildings, etc. must be placed on reverse side,) NEW INSTALLATION: - (No septic tank or seepage pit permitmak, ted if public sewer is available within 200feetJ PACKAGE TREATMENT SEPTIC TANK Sr-ze------------------- -------- ------- ----- Liquid 1Depth ----------------- ti Capacity --- ------ ---------- Type ---------- ----- Mciterial,--:-------- No. C 0 m p a 0�M�ee n t s ---------------------- Distance to nearest: WellW ------- -------------------�Founclation -------------------- Prop. Line ------------ ------- Total Len Vh LEACHING LINE, No. of Lines ---- �each line---- --—--------- Length t , ` 'D' Box Type Filter /V aterial - Y S4th _Filter Material VW------------------ ----- Distance Nnearest.-Well --- I _ Foundation- clation - -75 ft------ Property.4ine -05-e'-4- SEEPAGE PIT [ 1 .1 i I ---------- Depth ----- -------------- -Diameter --- I. ------ Number ---------------------------- Rock Filled YesC] No Water Table Depth"_--------------- -----------•---Rock Size Distance to nearest.oWell ----------- -------------------- Prop.,Line ---------------- REPAIR/ADDITION(Prev. Sanitation Permit#- ---------------- ---L- Date j Septic Tank (Specify Requirements) - I I J ---------------------------------------I Disposal Field (Specify Require I I------------------------------------------------Requirements'' J 114 ------------- ------ ---------------------- --------- ------- ------------------------------ -- ------------------------------------------------------ ----------------------------------- Z -------------------------------- ------------------------ ------------------ -I----------------------------------- - -------I---------- ------- ------------------- Z. ---------------------------------------------------------------------- (Draw existing and reqb ired-add iti-6n on reverse side) --------I--------------------- I hereby certify that I have prepared this application and that the work will be done in accordance County Ordinances, S o-rdance with Son Joaquin h District. Home owner or licen- sed State Laws, and: and Regulations of the Son Joaquin Local Health "I n sed agents signature certifies the following: lic:n- "I certify that in the performance of the work for which this permit is issued, I shall not employ any p J person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------------------- --------------------------- ------------------------------ By - ------- ----- --------------- Owner ------------- --------------------------------------------- Title fIf other than owner) - I - ------ --------------------- FOR DEPARTMENT WE ONLY APPLICATION ACCEPTED BY -----------i------ ----------------------------------------------------------------------------------- DATE -------- BUILDING PERMIT ISSUED I I ---------- - ------------ 4"ITUIO AL C� M NTE ---- DATE -------------- ---- #----------------- AD TS ---- - ------------- J�f --------------------------------------------------- - --------------------- ------------------------------- ---- ------- -0- ------------ Final."'Inspection by. -G4 - ........... ----- ------- ------ - -- ---------Date SAN JOAQUIN LOCAL HEALTH DISTRICT ---------- -- 'E: H. 9 1-'68 Rev. 5M.