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R 71 A 53 a FOR OFFICE USE: L a I APPLICATION FOR ITATION PERMIT FOR OFFICE U.S � ' --------------------------------------------------------- _ JAN 3 QCQRete in Tr'- ate) Permit No._ �_ /_____ ----- - s- ----------- ' ------------------ SAlNthiMW4*cI ifdCt1Q(ear From Date Issued Date Issued--j_.ff/779 H 4 fir, 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 ADD RESS/L TION _- , (.LJ_ (; / US TRACT. -Jc�� Owner's Name_- _- - _ off, . F O Address--- l-- - - - IBJ (A� ----------------------- ----------------City Zip �' .' Ph ne Contractor's Name_-_ -_- - _-_-_License /�'� ne � j 6 Pho Ins�allation will, server Residence❑ Apartment House Commercial ['j--'Trailer Court: ❑ ' . . -Motel ❑ Number,of,living.units:__L------------Number.of.bed'roo' ms __Gar-bilge--Grinder-= . ..__Lot�,Size- -r --- - r-a ---- _ - _ - Water Supply: Public System'and'name .. ... ------- ----------------------- -- Private ❑ Character of soil to a depth of 3 feet: , Sand ❑ ;Silt❑ `Clay ❑ • Peat❑ Sandy Loam ❑ 'Clay Loam ❑ _ ' Hardpan ❑ . Adobe /Fill Material_-_ If yes, type - (Plotlocation . N NEW plan, showinNSTALLATION: '" No?size of lotse tlocatio ic' to of system in relation towells, buildings, etc. must be'placed on reverse side.) i , ( p nk or-se p'a"-'g e `pit permitted if public sewer'is available within 200 feet,) ; PACKAGE TREATMENT''[ ] SEPTIC TANK' I i :. __Liquid Depth----,s,3-- ---- -- Capacity o. Compartments _.. Z— Distanceto niearest: Well -:_ . . .Foundation 5 Prop.- _-_ Line__ as - LEACHING - I LINE: [ ] No. of Lines Length of each line Total Length _ L D' Box -- Type Filter Material •.Depth Filter Material ry ------------------------------------------------------- A,- V Distance to nearest: Well '_-_ ____Foundation_-_ Property Line ---------------------------------- T SEEPAGE PIDepth 5 ---Diameter_ _ fir Number Rock Yes.F9—No E] Water Table'Depth---------- - _ Rock Size -------- --------------X / �i. �. � "Distance fo nearest:`Well F._ -' - `-' �F,_ Foundation r p e / r / -- _ .P o Lin REPAIR/ADDITION (Prey: Sanitation-Permit#" �^ _ -' M <,, , ,w,yw a --- --- Septic Tank (Specify-Requirements) -------- _._ _ £. Disposal Field(Specify Requirements);- --------------- .. - ---s I - --- --- ---"- r-^. 'I • - ---------------- ---_--------------------------------------------------- (Draw existing'and required addition on reverseside) -------------------------- I hereby-certifythat I have 1 prepdred this-application and that.."the ;work will be done. in accordance with San Joaquin County , Ordinances, State Laws; and Rules and Regulationslof the San Joaquin Local Health District. Home owner or licensed 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 kman's. Compensation laws `of",California.':... 3 p w Signed EO -- ---- --- - f wner i - = _ -- -- - ------ ---- Title_C�%G'- t (If other than owner) • a i r i _ ii-1 `A--`--FOR-DEPARTMENT'USE'ONLY.. APPLICATI N ACCEPTED BY ---- ! I' 1� a ------------------------ --- -----------------DATE _ ti DIVISION EBF LAND NUMBER. _ __, E ADDITIONAL COMMENTS-------------------- ----------------------- -----DAT----------------------------------------------------- E - -- -- .« , - -- - - --- ------------ ---------------- - -- - ---- Firial Inspection by. ��_-_ _ � � ....1._ _ ; -- - - -- - -- ---- -- - Date EH 13 24 SAN JOAQUIN.LOCAL HEALTH DISTRICT F8s 21677 REV. 7/763M