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PWr161%oJ%11vnr F_WK JAN11A11W4 rCKM11 <br /> . ................................................. <br /> (Complete In Triplicate) ! Permit No. <br /> This Pe It Expires I Year From Date Issued Date Issued 1.:-�S :� <br /> App at o s h re y ma a tote n oaqu n Loca eat Di r ct o�a permit to construct and install the work herein <br /> described. This application Is made in compliance with County Ordinance No. 549 and xlsting Rules and Regulations, <br /> r <br /> JOB ADDRESS/LOCATION . G'.. .......c' .... f.. .zkc . .; . ...�.CENSUS TRACT .......................... <br /> —Owner's Name . --r Q ................ ....................Phone .................................... <br /> Address .. <br /> - . . - ....................L �y- .:----...--•---.- <br /> Contractor's Namec__5 v fit- .. :. �--doUlcense #c ,�•/� PhoO 7. 1_, <br /> s Installation will serve: Residence MApartment House❑ Commercial-❑Trailer Court ❑ <br /> Motel ❑Other------------------,---- <br /> —Number of living units:...... __ Number of ooms ___ ___Garbage Grinder __` Lot Size ._ -------- t <br /> Water Supply: Public System and name ----- /X�vZ; - -Z^ -=------------•---•-----------------•-----•Privatet, ' <br /> _Character of soil to a depth of 3,feet: Sand❑ Siit❑ Clay ❑ Peat❑ Sartidy Loa day Loam❑' <br /> Hardpan❑ Adobe ❑ Fill Materlol ... If yes;type ..... ...... ......... <br /> w(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.j� <br /> NEW INSTALLATIONz (No septic tank or seepage pit permitted If public sewer Js <br /> /a�vailable within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANAK Size__ ! �.�/ U r ` <br /> •... ..... ... Liquid Depth �......-•-------. <br /> Capacity/JCO Type .��G aterlol__ - -- - -- No. Compartments _ ___.__ <br /> - <br /> Distance to nearest: Well ----4,Z2---------------------Foundation -T <br /> .-- Prop. Line ....` <br /> LEACHING LINE No. of Lines ill---------------- Length of nch line...... _U--_.........._. Total Length ,/,110..`...__. < <br /> 'D' Box ..-,�.-.- Type Filter Material A-"<�... Depth-Filter ' r <br /> -_-__-- . Material ��---- ---------------------•-_--_-- <br /> Distance to nearest. Well �.................. Foundation Property line kr. .._._...._. <br /> Or f. <br /> SIT [j Depth ../to.......... Diameter tO /7f Number ....... .....��z<.... Rock Filled Yes Jk No ❑ , <br /> d \ Water Table Depth __. ll......--.......•.................Rock Size __..s .................. <br /> _ Distance to nearest: Well __f�lv--------------------------Foundation ....I-C!_....... Prop. Line --_4___-------- <br /> __ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----.-----------------.----------_) 1 <br /> Septic Tank (Specify Requirementsl -.----•.-----..-------------------------------------------------------_. <br /> DisposalField (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 Sots Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health 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 Workman's Compensation laws of California." <br /> Signed -- ---- . Owner <br /> By ---•--•-••- lY. ck - •---•- - --- ---- - ------------- Title ...... - - ... .�'GC1t G'r cam._........ <br /> f other than owner) <br /> R EP T NT US ONLY,,_... <br /> APPLICATION ACCEPTED BY - -------- ......... ..... .. ........... DATE .1. -.30.- . ............... <br /> BUILDING PERMIT ISSUED ----- -----------------------•---•-------. . -----------------DATE -----•------------------•- --------------- <br /> ADDITIONALCOMMENTS ....-----------•---------.-----------•--------.-...-----------------------------------.:.-••---••--.:.... . . •. . -- ------------•--••--•---------••-•..... <br /> -- --------- ----- ----- --------------•------------...----------------------.•-----.....--•----•--•-.................-------•-- -.-._...------- ----------------------..----•----- <br /> --._..... --•--•-----------------• ------. .•-------••----•••••--.....-•--- ...............-•-•-----......-- ................ •------•---..... . -- -- ----------•--- --•---------............ <br /> _ ------ ----------- a�J;' .......................... ............. . ........ ............... ......... <br /> Final Inspection by; .............. <br /> -- ----- Date ._/..` ./...r� <br /> IM 13 24 1-6.3 He-v. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3x <br />