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FOR OFFICE USE: „� - /t p SAN-ITAT164 PERMIT Permit N AP)tICATIOA FOR €- r. _ _ u _ ermi o. �_7.�/ �.+: '� (Complet�in Triplicate) //- ----_ - A�__4�-----------(.,_, _Cly? _ Date issued _ _ this Permit Expires 1 Year From Date Issued 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/LOCATION _fJ---.(� A_---- - ----�o�'`'!�t''------------ -------------- -------------------_-CENSUS TRACT Owner's Name _ -------- -------------Phone Address __-_-----:�•1 _ City ------------------------------------ -- Contractar's Name - -------------------License # ------------ ------------ Phone ------------------ ----• - Installation will serve: Residence E1-4�partment House❑ Commercial:❑Trailer Court !❑ � 4 Motel ❑ Other ------------------- --- Number of living units:____-!-__-__ Number of bedrooms _,_____Garba_ge' Grinder--'FI'Q.... 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 E] ; Hardpan P ❑ Adobe ® Fill Material ---------- If Yes, type --- ------------------------ (Plot -------•---- - -------(Plat plan, showing size of lot, location of system in relation to wells, buildings,.-etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,j \' PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] Size-------—--- ::---Y----- - . "Liquid Depth -------------------------- ----- -----------------j-_.Maj r i # . p. Capacity ---------- __ Type f tenialNo 'Compartments --------------- Distance to nearest: Well ------------------- ------------Foundation ---------------------- Prop. Line ----------.---------------------- LEACHING LEACHING LINE [ I No, of Lines ------------- --._ Length of each line_____.____ Total Length _ ` ' ------ -------------- 'D' Box ------ ----- Type Filter Material %'---- -----------Depth �ilter Materials---------__------_- -•----_-------- Distance to nearest: Well _.-_------------________Foundation 77— �`Properfy Line --__.__'� = -------- ---- SEEPAGE PIT [ ] Depth _____________ ______ Diameter -------------- Number ---------------------------- Rock Filled . Yes ❑ No i❑ Water Table Depth ----------------------------- i ----Rock Size ----------- Distance to nearest: Well ---------------------------------•-------F u ______.___-_ Foundation -------- Prop. Line ------------ f i REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date+---_`-_-_---- j Septic Tank (Specify Requirements) -------------------------------- ----------f.. . I -----------------------------=--= ---:----------------,..--------------------------- Disposal Field (Specify Requirements) -_ ___.__41' .•cr,- -- ? ---------- ------------------------- ----------------------------------------------------- ----- --------- - ------------ raw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will..bedone,in accordance_with San Joaquin ,County Ordinances, State Laws, and Rules and Regulations of the San Joaqun.Local:Health Distric#. Home owner'or licen- sed agents signature certifies the following: 1 / F "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's-Compensation laws of California." Signed --- --------- Owner BYd P --------------- ----- -- Title------------- - I other than owner) ------------- ---- FOR I DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_______.____ -- Z' I ------- ---------------------------------------------------- -------------- DATE _..__.1�'�-�- ------------- BUILDING PERMIT ISSUED . . -___ -- - ,r_------- - DATE ADDITIONAL COMMENTS�� -- _-- -.f,:__ ------------------------------------------------- ��_A.2 -- d -am - AV ------------------------------------- j -------------------------------------------------------------------------------------------------- -----------------------=------- FinalInspection by ------------------------------ Date SAN JOAQUIN LOCAL HEALTH DISTR[CT N. E. H. 9 1268 Rev. 5M f