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FOR OFFIi APriCATION FOR WNITATION PF 'IT Permit No. ............. --------- -- (Complete In Triplicate) ---------------------...............- - -.-_----------------I This Permit Expires 1 Year From Date Yssued Date Issued ...67 .J/ 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/LOCAT N �GJ-- - - ...-.CENSUS TRACT ------ ------------------- Owner's - --------------------- Owner's Na7me - - GtiQlt2J-- - L -------- - - -- Phone Address rf � .... - City . ------------- ---...- Contractor's Name _---- --------- - - '�E��' a---- - - --- --.License #p2.�.y/_20 Phone 74r.CP.�o`.�7-. i Installation will serve: Residence E] Apartment House❑ CommercialOrailer Court ;❑ Motel ❑ Other Number of living units:._......... Number of bedrooms ___.--.--Garbage Grinder ---- Lot Size -._--...---_.---.-_------------------_.- 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 ❑ Adobex Fill Material ------------ If yes, type -_--.._-..-.-..-_.--._.- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size._---------------------_.._____ ........ Liquid Depth ---- __.-._-._..-_- \ Capacity --- --------- Type ------ ------ --- Material. No. Compartments .------------....-- Distance to nearest: Well .-_____-. ------------------...Foundation ---------.----_._--- Prop. Line ---_--_----_ ----- LEACHING LINE [ ] No. of Lines Length of each line _...._----- Total Length .._---------------------_- S 'D' Box ............ Type Filter Material --------------------Depth Filter Material -..-.-------.----.--.------------------.--.- 1 1 Distance To nearest: Well - ----- Foundation -____---------__.. Property Line - PIT [ ] Depth _.__ ----- ---- Diameter -----.- -------- Number ---------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------- -- ----..Rock Size -------------------------- Distance to nearest: Well --------------------------------- ......Foundation -------------------- Prop. Line _------..--------.--- \ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------_-------.-- Date ---- ............-----------------) Septic Tank (Specify Requirements) .. ...... ......----_ -----. --------- -- ------- ----- - --_--- ._._-_.. Dis osa,, Field (Specify Re uirements) -.--..---------�... ..........--..-----.+------ -- ------ - - ------------ - xa-�---- _ - ---- _ - -----_ -- ----- ------- ----- -- -- ---- ----- ------ --- ---- - - -- --- (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 perfor nce f t e work for 'ch this permit is issued, I shall not employ any person in such manner asto bee su 'ect to o ma 's ompensatidq la s of California." Signed --------- ---- -- - - - - --- - -----------.- Owner By . - .._.. — --- - ----- ------------ Title _.. - .... - - - - - - ---------------- (if ---- ------ (If 0 an own FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. -- - - ---- -------- ------ - - - - -- - - ......- - . DATE ---- ' - BUILDING PERMIT ISSUED ----- -'----- --------- _ ----------- ---------------------- -- -- . . .. --- - -- -------DATE ADDITIONAL COMMENTS . - - . .... __., ---------------------......... ..... -.... ... ----- - — - -- ----- ---- - -------- ----- ------------ - ----------------------.--- ----- - - --------- - --------------- - - - - - - - -- ------ --------- - t� [ Final Inspection by: -..... _._.. -....----- - .-- ------- - - -------- - - -.------------.Date _.. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M G