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r-0F OFFICE; 0SE' <br /> i A TY°r�CA f 1ON FOR iiiNTATnON; - IEftM1-R s 'an O.Glynt _ <br /> Permit No. <br /> (Complete in Tritrolic:ate) <br /> Yt.... ......... <br /> Date Issued . <br /> ..­77-/_ This Permit Expires a Year From Date Issued <br /> ..r7:/.� . 13 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .. .. ... '.._5...... _.......... .....CENSUS TRACT ................... ... <br /> Owner's Name . _... to � _....S-C _ / <br /> �_......... -.... =`�'------------------ ------._.-.--__-.-_._....:.............�%,. ....__._......_..Pitione <br /> Address ...-.- . -'7�. ...._ � s o+e,�?..'- -1� ` . .............. City ...J� Dc�Jvad,--. .._...... <br /> Contractor's Name <br /> '�.�-.� JS�.�. 4a.........................License #���. 1`�.�.7�......,.. Phone ..�.�i'_F�.�Z..... <br /> Installation will serve.. Residence ❑ Apartment House,( Commercial ❑Trailer Court 0 <br /> Motel ❑Other -...�d.T�tc e <br /> -------------------- --- <br /> Number of living units:...../... . Number of bedrooms _.3_._.._-Garbage Grinder ............,Lot Size . ....�.. K J <br /> Water Supply: Public System and name ............................. --------------------------------------....................................Private (q <br /> Character of soil to a depth of 3 feet. Sand 0 Silt❑ Clay rA Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material -----------. If yes, type ............................ <br />! (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANKf ] Siae..>----t��k. <br /> ........ Liquid Depth_..�r ...?.,...._ <br /> Capacity ._ ------ Type . _ Material . No. Compartments ....c�............. . <br /> r <br /> Distance to nearest: Well . ....'r?......................Foundation ...... Prop. Line ....��. f...... <br /> LEACHING LINE [ ] No. of Lines ........ ............ Length of a ch line......?Q............... Total Length ......... <br /> D' Box 4 <br /> ..... --.__ Type Filter Material ....................Depth Filter Material .. ........................••---.. <br /> r <br /> Distance to nearest: Wel( .......�`�.�...~__ Foundation ._.._.. �.r.°�...... Property Line ..J'...�............. <br />— SEEPAGE PIT [ ; Depth ...... Diameter ................ Number .............-................ Rock Filled Yes ❑ No ❑E <br /> Water Table Depth ------------------•- .........................Rock Size -------------------_ <br /> Distance to nearest: Well --..-•.............. ...................Foundation ........_........... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ................................. .......... Date .......................--.........) <br /> SepticTank (Specify Requirements) .-----............. .......................... -----------.-......_......................................................................... <br />.� Disposal Field (Specify Requirements) -_- -------------------................. ------------•-•---•-------- •------ -•- --------- ........_- ----._....--•--------_ <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 San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Wealth 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 Work an's Compensation laws of California." <br /> Signed ..... ... �.,1)...... -- • ------------------------------••---•--....-------........... Owner�' <br /> By •. .. .. ...... .... .F- Ti <br /> _ tie ... . <br /> (if other than owner) <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... .... DATE ....... 3..._ <br /> BUILDINGPERMIT ISSUED ... ..... ............................................................................... ..............DATE .......................................... <br />_ ADDITIONAL COMMENTS ------•...........................................................-- ..................................................................................._-.--- <br /> ......--•..........................••-•-•••...............................•--...........••--•-•---•.......--•-------------•---•-•-•--••-•-•••-...............--•......_............-- ---..............-- <br /> ..-------•...............•..-----------:........------........._..---•---•--...--•_...._...............-•---•----........_._.........•-•.........•-•-- <br /> ._.....-•--•-........ <br /> Date <br /> _ Final Inspection by: - <br />