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ti <br /> FOR Or:FICE USE � y�APPLICATION FOR OhITATA PERMIT <br /> • I (Complete in Triplicate) Permit 110 ,��•- <br /> I •, <br /> � <br /> Date Icsc . <br /> , . <br /> :eJ . •` <br /> -•--•••• • This Permit Expires 1 Year From Dote Issued <br /> Application is hereby tirade to the Sun Jowl in local Ht:;jlth District for u permit to construct ❑nd instoil th;• 6Jrk hors"tl <br /> This application is made in compliance with County Ordinance No 5.19 and existing Rules and Regutot 3115. <br /> JOB ADDRESS;L.)CATION f� / �. / /t��/L'C �h��' 11� CE.ASUS iRACi <br /> Owner's Name �7 .1 fC ^ ' <br /> �� �.' <br /> �, <br /> •t 7 Y <br /> i <br /> Address E'SS/ City—I—A-W( C/ Z p t/ 5 7 (•' a <br /> Contractor's Name `r���71"t C`'lL'r( n (C'�tres�•' license # Pit3 to <br /> Installation will serve, Res.den,v 7 t Apartment House I _I f_ommercic.l [) Trailer Court I I <br /> Motel ❑ erOths, <br /> G:„I <br /> Number of living units: / Number of Lcclronms Garbage Grinder. lot Size <br /> Water Supply: Public System and narTte F'rrvate i_] <br /> Character of soil to a depth of 3 feet: oand X Silt r) Clay [] Peat [J Sandy loom ❑ Clay loam j] <br /> Hardpan [] Adobe (_] Fill 1.Attteriol If yet, 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,) Q <br /> PACKAGE TREATMENT O SEPTIC TANK Size liquid Depth <br /> Capacity r 0o Typ,� 4(/PCc+" Mutmiol edh< -^rre .No. Comporiments — w' <br /> Distance to near'>st: Well /CIO •t+ Foundation .>Id Prop. Line 73 <br /> LEACHING LINE O No, of Lines length of each no �QD / Total Leizgth f` <br /> D' Box ( Type Filter Material$tyf•-/M•k0epth Filler Material J ...~, <br /> Distarct>to nes wr ?- Well / Od f 4- Foundation >/Q.. Property line <br /> Rock Filled Yes No <br /> SEEPAGE PIT ( ?, Depth Diameter Number ...... ... . . .. .. . ❑ <br /> a <br /> ..r <br /> `Nater Table Depth . ..........Rock Size.. <br /> DLiunce to tworesh Well ......Foundation . Prop. Line <br /> REPAIR/ADDITION (Prev. Sanitation Permit # .......Date <br /> n Septic Tank (Specify Requirements) - fair 3 <br /> Disposal Field (Specify Requireme •s) <br /> _ .. . .. ...... .. . . <br /> (brow 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 County <br /> Ordinances, State laws, and Rules and Regulations of the Son Joaquin Local Health District, Home owner or licensed agents <br /> br: <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner ab <br /> to bee ub c1 to Workman's Compensation laws of California." <br /> SignedC,�f ( Owner <br /> ;r. <br /> Title <br /> (If other than owner) <br /> R - ONLYj <br /> APPLICATION ACCEPTED BY . . r �"— �� DATE <br /> DATE <br /> DIVISION OF LAND NUMBER ./�• zv yr r.l <br /> '� <br /> ADDITIONAL COMMENTS c'�••3<� ,� ,.;�,r .t4. �j.. r 1,'-<a:- _ <br /> / __ Date <br /> Final Inspection by: - " <br />- rss 2161' UV ilio 31 <br /> (11 13 24 SAN JOAQUIN LOCAL HCALTH DISTRICT '` <br />