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FOR OFFICE USE: E <br /> APPLICATION FOR nANIT1AaTIONI'ERMITPermit Noi(Comlete Triplcie)—­ <br /> p <br /> -------------- <br /> ----------------------------- Date Issued <br /> This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This applicatio: is made in compliance with County Ordin8nce No. 549 and existing Rules and Regulations. <br /> ---------CENSUS TRACT ......?-1-7-------------- <br /> JOB ADDRESS/LOCATION' ------ -- --- -- ------------------------ <br /> ----------------------------Phone - -------- <br /> Owner's Name __64--- ------------------------------ ------------ <br /> city ------------------------------------------- <br /> Address --------------- —---------------------------------------------- ------------ <br /> I l f ai_ Phone <br /> 0 Contractor's Name ------ ----------- -1icense # _-.1-4k <br /> Installation will serve: Residence 'Apartment House Com ercial F-ITrailer Court E] <br /> Motel E] Other --------)10- -- ---------- <br /> I G X: <br /> Number nits:-- ----- Number of bedrooms ----Q9----Garbage Grinder ------------ Lot Size ---- Z15L ------- ------- <br /> m bf,living u <br /> -------------------Private <br /> Water Supply: Public System and name ------------ ------ ------------------------------- --------------------------------------- <br /> P at❑ Sandy Loom -E] Clay Loam El <br /> Character of soil to a depth of Veet, Sand'E] Silt-E] Cloy E-] k <br /> if yes, type ----- <br /> Character <br /> Aclol�e-E] Fill Material _-._____.__ if <br /> buildings, etc. must be pl.aced on reverse side.) <br /> {Pl-ot plan,- <br /> .,showing size " f lot-location of system in relation to <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENV,`[�-] SEPTIC TANK Size--------0-4 -4.9 Liquid Depth --------------------------- <br /> V..,Capbcity --- No. Compartments -_---.rte=--•--_---- <br /> ---- Type Materia. <br /> - <br /> • Distance to nearest: Well - -----------:--,0- ---- <br /> -------- ---Foundation --- <br /> ---- Prop. Line --- <br /> 4� <br /> No. of 'Lines--4 ne-------- ....0--------- Total Length .. . ......... <br /> Length-�f each Ii <br /> LEACHING LINE X N . 1-------------------Depth <br /> ..I <br /> I ." �-� 11 , Material ---------------------------- <br /> 'D' Box ype�.FilterJ Materia 1-------------------Depth Filter -------------- <br /> bistd' �"re'if: W <br /> ;­ ­. liori . ---------Property:..Line <br /> el I Fickundial <br /> Distance to nea <br /> i -r R6ck Filled Yes a No C) <br /> • —SEEPAGE PIT_ -W�� -Depth -------GqJ------- Diameter ...... N 60be w� _7�*f.... ... <br /> Water Table Depth -------------- e'___j--------- �'_Rock Size - __�l------------------ <br /> Prop. Line ... ........ <br /> _4 .DIistance to nearest: Well -------- <br /> REPAIR Permit# -------- ---------------------------- Date ---------------------------------- <br /> /ADDITION(Prev. Sanitation - <br /> Septic Tank (Specify Re'quirernents) —---------- --------------------------------------- ------------------------------------- -------------- <br /> A91P --- ---------- --- -- ----- <br /> Disposal Field (Specify Requirements) ------ _, --- -- <br /> ------------- ----------------------------P---------- --- ------ --------------------- ------------------------------------------ ---------------/......--- ...I <br /> ------------------------------------------------------------------ --------- --------------- ---- <br /> ------------------------------------- -----------------I—------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I ha�ve prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or.licen- <br /> sed agents signature certifies the following: <br /> "I cei4ify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become-subject to Workman's Compensation laws of California." <br /> Signed --------------------------------------­�,-------------------------------- ---------------------- Owner <br /> --- - ------------------------- --- ---- -------------------------- <br /> By ------"o . ----------------- --------------------- Title - <br /> (If other than owner) <br /> FOR-DEPARTMENT USE ONLY <br /> 7?� <br /> APPLICATION ACCEPTED BY ... --------�__ 7- -------- DATE -------------- <br /> BUILDING PERMIT ISSUED <br /> D -------------------------------------------------------------------------- --------------- ------------- DATE -------------------------- --------------- <br /> ADDITIONAL COMMENTS ------------------------- - <br /> � ------------------ --------------------------------- ---------------------------------------------- <br /> ---------------------- --z, I- I <br /> �_�i`---------------- ------------------------­--------------------------------------------------------- <br /> --------------------------------------------------------------------------------------- --------------I---I,- ------------------------------------- <br /> ---- --------------------------------------------------------------------------------------------------------- <br /> ------------------------ <br /> -�-—--------------- <br /> D a t -0------ <br /> ------------ ------------------------ -- -------------------- ------------------------------------------------------------ <br /> Final Inspection by: ----Z, ---------------------;-------?--------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />