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12-29--:.999 02:14PM F1?Ort TO 3694223 P.01
<br /> FOR 9FFtCE USE,
<br /> �� APPEICA710N FOR SA.IYirAnol� PERMIT
<br /> ... . . .. ................... ....... Peurft No, . ....
<br /> (Complete in Triplicate,) _
<br /> �............ .............. ................ - Date
<br /> This Perm4 Expires t Year From,Date Issued
<br /> Application 4 hereby mode to the Son Jeoquin Local Ffeallh District for a permit to rnnstruct and instaii the work herein
<br /> desaribcd.This oppliGotion is made in Co-
<br /> th Crvnty Ordir,zift`e No. 549 onel ex;st;ng Rule: and Regulations:
<br /> JOB ADDRESS AOCAT 17-Y 7�.r L fG'LCP_A.- /J CENSUS TRAC
<br /> .,
<br /> Owner's NaTne ..... ...^..]7....{r"1.....err.�............1%x.... .......... ........ ...,.... .. .,, .... ..Phone ....... .......-.---.--. ...,---�-- �.
<br /> Address ...�.0.. 5 ....� ,r!7 !"M..., . ...... .... .. .... .....C!:y . ........................................ i
<br /> Contractor's tJaeno .
<br /> 7, .�'C • . .... .., Licansa 0 .... ... . ......... Phan* .. ......................
<br /> ..�
<br /> installation will serve: Residence((Apartment Nouse 1 Comrr:emc of r1railer Ccurt n
<br /> Motel[:Other ............. /
<br /> Number of living units:......... Number of bedrooms . .......(}crbaye 3rincer ". . Lor 5i20% .�J. 3.. ........
<br /> Wow Supply: Public System and name . .... ...:........................ .. ....... . . ..... . ................ ..-.....:..............Private
<br /> ChproCter of soil to a depth of 3 feet, Sond 0 Silto' Cloy ❑ Psar❑ Sondy Loam ❑ Cloy Loom 2--•
<br /> Harcipon I_ Adahe Gi Hit,Material............If yes,type...... ............. . . . .
<br /> (Plot Dian showing size. of late leeation of systarn in relation to +veil$, buildings, etc. must be.piaeed on reverse side.) !
<br /> NEW INVALLARON: (No septic fank or seepoge pit permitted IF public Newer is ovoiloble wirhih 200 feet„ V
<br /> � .
<br /> ) ..,ze...a•r'� r,.K.. . �.6................ Liquid Depth .�-? .........:..,..
<br /> PACKAGE�'RwATMFhiY (] 58pTIC TANK E� e' .`�, q p ..._.
<br /> Capacity..4eG I. Type r , Compartments �..--....
<br /> Distance to nevrat6 Well ............. Favndati n. _..... �f
<br /> Prop,1,ine .,.,
<br /> LEACHING LINE (] No. of Lanes ...Z................. Length of each line �� ��.., Total Length �S�y iy
<br /> f �•
<br /> D' Sox ..(fi e.. Type, Filter Material 'M4A......Depth Filter Materiel 1.d:..........................................
<br /> Distance to nearest, Wel[ _/op,.• .....•. FoJ,'rdatior, ...r .. .......... Property Line
<br /> SEEPAGE NT Depth .. ............. Diameter Z K..f.' Numibe. ................ Rock Filled Yes (;—Iso C❑
<br /> Water Tabio Depth ................................................Rack Size
<br /> Distance ro nearesr, We!I ............_...........................Foundotion ......... .......... Prop- Lina ..............
<br /> I REPAIRjA ZOITION IPtBv.Sanitation Permit#............................... Dote .................................
<br /> 1 _
<br /> Septic Tank{specify Requiremcntsl .................................................................. .................... ..........
<br /> { Disposal Field (Specify Requirements) ........................................................................
<br /> # ........................................1.. ........ 1
<br /> ..,,.. ...... , „ '..........:.. ...... ,.........,..,., . ....... ................. ...... . . ..................... ...,... .,,.. )
<br /> (prawa,uisting pod required additlon on re,verse side!
<br /> t I herby certify that I have prepared Ale application and than The week will be done in aeeordarics wilt+ San Joaquin
<br /> County Ordinances, $fate Lows, and Rules and RtgulgRans or tier San Joaquin Local Heahh District.Home owner or ilosa-
<br /> sod agents sisp ertwiee sortifiee the Mlowiny=
<br /> "I certilI r that in the perf once of the work for which this permit is Issried, I shall not employ city person in such manner
<br /> as to became subject ton s C eatien Ws of California."
<br /> Sloned ....................... ..'.... � (r .. .......................Owner
<br /> 13 y..:.............................
<br /> ...................... .......:.-............................:..,.... title
<br /> t (If other than owner)
<br /> ( FOR DEPART CNT USC ONLY
<br /> APPLICATION ACCEPTED BY.. ............. .........,...._...........,....... .. ',.. .......................DATE . Z..�. ..~ . ..... ....
<br /> BUILDING PERMIT !$$LIED . .....
<br /> .. .: .............-......... ..ELATE .
<br /> ADDITIONAL COMMENTS—
<br /> '
<br /> ....................................,.......I..............................
<br /> + •Final....., alonby. .......Lfte'?'. ...rl i /!Aa.... ..... .'..,. ..Dat.....�y.,-. ••�. .......•...
<br /> SAN ITN LOCAL NEA6H DiS1Rl T
<br /> C
<br /> ? E.A.9 W40 Rev.soM
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