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E USE- <br /> ' XNITATION PERMIT <br /> FOR OFFICE <br /> K41 C, A.APPLICATION �6k S Permit <br /> No. <br /> (Compli-ti in Triplicate <br /> -- -------- <br />---------- ---- ---- L Date Issued <br /> _j - ,'- .. This Permit Exfi2es,11 Year-From Date Issued <br /> ---------- ---------------------- <br /> Application-is-hereby-made-to-the Son tioaquin-Local-Health-District-for va­permlt-to--construct and install the work herein <br /> described. This application is made! in.compliance with County Or8ihance-No' 549 and existing Rules and Regulations- <br /> -- - ------------ <br /> JOB ADDRESS/LOCA ON -- ------ <br /> ------ - --------- -- <br /> ------- -------- CENSUS TRACT J----J"-7 <br /> .-Phone _,4G4/---844Z---- <br /> ....... <br /> Owner's Name ------ -----------------I/ <br /> 71 - ------------- city --- 4. <br /> -------- <br /> I Address ---------- pegn4---10_11"504--------- <br /> 4 <br /> # --- Phone <br /> �tContractor s Name <br /> Residence' 'Apartment House,E] Commercial E]TrailerCourt E] <br /> finstallation Wil serve: Re's 77-1 i <br /> �-, I / -I " - - <br /> Motel El Other --------------------------------- <br /> ------------- <br /> Number of I ivknge un Iso <br /> its..Y4,_-__`!'NP m ber,of bedrooms _AZ------Garba-ge Grinder Lot Size -------- -------------------- <br /> -------___-_____________------Private El <br /> Water �'u'�?Iy�P�blic System andjname, <br /> Sand'E] Silt ❑F-1 Clay E] Peat El Sandy Loam ,D Clay Loam_E1 <br /> Character of�'S­0114o a depth of 3 f�et: <br /> Adobe Fill M'd'terial ----- ------ If Yes, type ---------------------------- <br /> Hardpan El <br /> I(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> tank or seepage pit permitted if public sewer 1% available within 200 feet,) <br /> NEW INSTALLATION�­(Nciseptic I �) <br /> i --- -_ Liquid Depth ---------- <br /> PACKAGE TREATMENT SEPTIC TANK[ I Size._-_------------------------------------- <br /> Capacity --------------------- Type -------------------- Material------------ ------- No. Compartments ----------- <br /> e ---------Foundation ---------------------Prop-Line .------- <br /> D�istance,to nearest.. Well ------------- <br /> LEACHING LINE No. of Lines ---------------------- _ Length,of. each line------_-------------------- Total Length ----------------------------- <br /> ,A - ­,�­.f,— J . 41.1', - <br /> 0I. -----Depth Filter Material -------------------------------------------- <br /> 'D' Box Mdterial ---------------- <br /> ----- Property Line. -------------•--•---•--- <br /> Distance to nearest: Well ------------------------ Foundation -------- --------- <br /> SEEPAGE PIT Depth -------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 Nl� <br /> WaterTable Depth ----------------------------------- ---------- -Rock Size -------------------------------- <br /> Distance to nearest. Well __-_----_-----------------------__- <br /> ---Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- <br /> --- --- ---- <br /> Date ----------------------------------1 <br /> Septic Tank (Specify Requirements) ----------------------------------------7------------------------- ------------ - <br /> 1 <br /> Disposal Field (Specify quire0 A- - QAA ,.-- A10 -- <br /> - AAl -------I------ pay &x1f,3Ams---PIT---------- <br /> --- <br /> *ae_-_-a-Pv IT----------------------- <br /> - <br /> -------- ---- -- <br /> Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, Slate Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify 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."ner <br /> --------------- ---- ---------- - ---- <br /> Signed ------------------------------------ ------------ -----A------ OY <br /> JYA>A'I *Wr-!Z ----------- ---------- Ode ------P- "i-Of--- - -------------------------------- <br /> (if other than owner) <br /> F ^ DEPARTMENT USE ONLY <br /> By <br /> APPLICATION ACCEPTED 8Y --- DATE -----------------------•- <br /> - -------- ---- -- ---------------------------------------------------------------------- ---------------------------- _ <br /> BUILDING PERMIT ISSUED ----------------------:---- ----------------------------------------------- --DATE ------------------------ ---7 <br /> ----------- <br /> ADDITIONAL COMMENTS ------------------------- -------- - -------- -- --------------------------------------- <br /> ------------------ ------------------------------------ ------0 - ------ --------------------------------------------------------------------------- <br /> --------- ---- --------------- ---- - ------- ---------------------------------------------------- -- ------------------ --------------------------------------------------------------------- <br /> ----- ---- ---------- -- --- ----------------------------------------- - ------I— ---------!; <br /> ---------- --- ---- ----- <br /> _J---------------------------------- ---- ----Final Inspection by: ------------------------------------------------------------------ ----------------------Date ----- V- ----- <br /> I <br /> ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />