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APPLICATION VW STATIC" pgoff <br /> .....----------- -_--_-- <br /> (Comph"in Permit No. L 3 ---7 <br /> - .. <br /> ...................... <br /> -•................. . <br /> This Permit Eupires 1 Yom morn iaft <br /> IN I <br /> Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> rdeuxibed-This application is made in compliance with County Ordinance No. 549 and existing Was and Regulations: <br /> { • TRA <br /> JOB ADDRESSAOCATION _ ..Jhle�5!W_�_+_�e _L1-Tew� , -/�o:of _Y <br /> -•..................._.._. <br /> Owner's Name ........ ......._ - ...._..... r_.__.-.............r. Phone ''- ...................- <br /> Address <br /> -- -----Licence#` '_ .' I�4i.�,'-Y2_1 <br /> Contractor's Name r-- - -- - <br /> Installation will serve, Residence❑Apartment House❑ Commercial❑Trailer Court ❑ o <br /> Motel❑Other j`?u .-L <br /> Number of living units:_-- -_-___ Number of bedrooms _-'= ____Gwbage Grinder . !�Siz® A w <br /> -------• -+.....�� <br /> (Nater Supply: Public System and name -----------------•------------------------------__.�._._._.-__:_.�.-----._.....-=--------------......Private� <br /> Character of soil to a depth of 3 feet: Sand a Silt❑ Clay ❑ Peat❑ Sandy Loam a day loam❑ <br /> Hardpan p Adobe❑ Fill Material----------- If yes,type <br /> (plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must- be pktced oh reverse side-( <br /> 2 <br /> k NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,! N <br /> PAMGE TREATMENT ( ] SEPTIC TANK j Size..................................... . ........ Liquid Depth ....................__... <br /> .� <br /> t <br /> Capacity --�A��44yType a,..._-a:--.___ Mcterial_____��c.__-_ No. Gompctrtrnents <br /> Distance to nearest: Well- -----------------.__Foundation---��------------Prop:titre� fl—, _----- <br /> LEACHING LINE ( ] No. of Lines -------- Length,of each firm---.-�-_`_- - Total Len th _._�------_------------_. <br /> 'W $ox .--- _-__-- Type Filter Material .._ -�'.....Depth Filter Mawwl _..- �$___._. __._... . <br /> Distance to nearaests Well ------- Foundation .....C.............. property Lim .......... <br /> 4EEPAGE PIT 1 Depth -------------------- Diameter Number ----.__ Rank Filled Yes ❑ No ❑ <br /> Water Table Depth -------------------•_----------------------._hock Size ..._---- -----..-.....�. <br /> Distance to nearest. Well ------------------------- -_-_-_foundation line <br /> - - - prop. .. ..... ..... <br /> MAIR MDITION(Prev. Sanitation Permit# ___-....................................... Date --------------------------I <br /> SepticTank (Specify.Requirements) ...............- - ......................................._-..............-.....--..............._. ......_...... <br /> Disposal Field (Specify Requirements) --------- ---- ----------•----------------------------------------- ---------- ------- ................................. .... <br /> =•----••-•-------------------------------•-------•---- --------------------------------------- -----------------------------------•-- -- ----- <br /> ---­----------------------------------------------­_­---------------- <br /> ------------------------------------------------------•----••----------------------------------------­---------------- —---------------------------------------------------- <br /> (13r.ow <br /> ---- ----------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the we& will be done In mance. with Son JoagWn <br /> County Ordinances, State Laws, and Ruk*-and Regulations-of the San Joaquin local Health District. Hope ear of <br /> Haw- <br /> oW agents signature certifies the,foliewh <br /> "I certify that in the performance of the work for'which Reis permit Is Issued, 1 shoill not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of C.olifornda." <br /> Signed------ ! !)!- ------------------------------Owner <br /> BYr - . ... Title --•-- ------•----------------------- ---------------------- ------••---- <br /> (lf.other erj <br /> FOR DEPARTMMY USE ONLY <br /> APPLICATION ACCEPTED BY :- -• 9.4_--------------- - - -•-----•--------------•-------=---........... DATE <br />{' BUILDING PERMIT ISSUED ------------------ - ---- -- - -- --- - --- --- --- -- __ <br />� - <br /> - -.--- -- - - - -- - --- - ----------------•----•-•--......----..DATE ..........................----------------- <br /> ADDITIONALCOMMENTS --------------- --------- -----------------------=------- ----=---------------------------------------------------------------- ----------------- --------- <br /> - --•------------•-------- --------------------------------------------------------- ....-.------------- ------ ----- ------------ <br /> -------------------- -----•-- ---------- ----------- ---.----••---...... -------- --------- <br /> . <br /> -- ------------------------ <br /> •--------- - ---------- - <br /> Final Ins ection#� • ..-- ILIX_ ------ ------------• - ---- -•--•- ----- --- -- ----------date ----- <br /> EM 13 2h . 1-68 neve 1qf SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 <br />