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FOR OFFICE USE: APPwLICATIO N FOlUSAWIRATION PERMIT G/ 9 _ Permit.No. _ 3 _/ _- ._ _ _F•(Complete in Triplicate) h- J ------ _ .. _. _.„ Date.l ssued�_V- 0? ----_-__----- This Permit Expires 1 Year From Date Issued 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/LOCATI .---��t�.� ------��-------- ' . _ ----- ------- ---CENSUS TRACT -------------- ----------- Phone,O -1--�7D----Owners Name --- ---- _ Address --------------------- ----------------- License # ---- PhoneContractor's Name - - jtI, Installation will serve. I Residence`r�Apartment House-F] Commercial :E-]Trailer Court 1] c �. Motel ❑Other ------------------------------------------- Number of living units;----C?----- Number of bedrooms --2------Garbage Grinder ----------- Lot Size -- --- ------------------- - Water Supply: Public System and name -------1------------- --------------------------------------"--------nd---Loam-€--- ----Cla --LoamrivateX - i Character of soil to a depth of 3 feet. Sand ❑ Silt,,[] y ❑ ❑ Sandy ❑ Y ❑ Clay Peat S � Hardpan ElAdobe�Fill Material --------- If If yes,type ----------------------------- (PI'ot plan,-showing size o0ot, iota#,ion 3of �system-i' relation to wells, buildings; etc. must be placed on reverse side.} NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK:( ] size------------------------------------------------;Liquid Depah - ----------------------- D; Capacity -------------------- Type ---------------- Material..------ ----------- No. Compartments, -----_....------------ pDistance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------_- ------- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------- ---------------- -Deth Filter Material --------.__________ '17' Box ------------ Type Filter Material ------------------- p --- ---------------- Distance to nearest: Well ------------------------ Foundation ----- --------.--------- Propeety Line_---------'______-_.----- . SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No Water Table Depth ------------------------------------------------Rock Size -------------------------------- a - - Distance to nearest: Well _______________________________________ Foundation ----- -------------- Prop. Line ---------- ------------ REPAIR,/ADDITION(Prev. Sanitation Permitt# ----------------------------------------- - Date __--_-- _ - ------------------) 1 Septic Tank (Specify Requirements) --rg � (�l�t --- -- -------- ---------------- Disposal Field (Specify Requirements) / Je-- --- 'tlr'`.c'------`-------------- ` -------------------------------- ------------------------------ ----------- -- -- --- - ---------------------------------------------------------------------------- ---------------------------------------------------------- - (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." i Signe --------- - ------ ----------------------------------------------- Owner ---------------------- -------------- - BY - - ---- ----- --- ---------- - - ------------------------ --------------- Title �- --- ---- - Ce (if other than owner) FOR DEPARTMENT USE ONLY r.1- APPLICATION ACCEPTED BY -------�--�V---[-------------------- -- DATE • ---------------------- BUILDJNG PERMIT,:,ISSUED ------------------- ----- -----= -- -------DATE ---------- ------ ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------------------•---- ----------- --------- _ ------- _ -- ------ r __ ' `=-------------------------- - -- Final_I.nspection by: - •A... ----------------------------------------------- Date _ T F-�? SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M