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FOR OFFICE USE: <br /> APPLICATION FOR NITATION ( MIT <br /> -------------------- -- -------------------------- Permit No., <br /> (Complete in Triplicate) , <br /> ------------------------------------------ ------ <br /> - This Permit Expires 1 Year From Date Issued Date l.ssued . _e,:6~,7O <br /> Application is hereby made to the San Joaquin Local Health.District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and exist'�SIXTTR ( <br /> and Regulations. <br /> _ 0JOB ADDRESS/LOCATION-/ ----C.Vz-- - �L� - . - ET -------------- --_--- <br /> 'Owner's Name ------------------------------------------------------ <br /> ----------------------------- - ------------Phone ------------------------------------ <br /> I <br /> ------------- ----- --- <br /> Address �- - -- ------- - City A14 -------------------------------------------•------ <br /> Contractor's Name ----X"Proi- -----------------------------__.----License# F / ./" ---- Phone <br /> Installation will serve: Residence$Apartment.House❑ Commercial :❑Trailer Court i❑ <br /> Motel ❑ Other --=----- ----------------------------------- ` <br /> 9 <br /> Number of living units:..__/____. Number of bedrooms _. — Grinder l�_-- Lot Size -1V�-- G'------------ <br /> h. <br /> Water Supply: Public System and name _702e"X,992�_��/--Alme5_0—--------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay Peat❑ . Sandy Loam X Clay Loam:❑ <br /> Hardpan ❑ Adobe'0 Fill Material ------ ----- If yes, type -------------_--_------__- <br /> (Pl'ot 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 lank or}seepage pit permitted if public sewer is available within Zap feet,] <br /> PACKAGE TREATMENT,.,[] ASEPTIC TANK[ ] Size_ -.------ q p <br /> -- -- t --- -- - Liquid Depth _:-------------- --- <br /> -"" Capacity -------------------- Type --------------------- Material ------ No. Compartments -----:-------_- <br /> Distance to nearest: Well __________-_____----------------Foundation ---------------------- Prop. Line --------- ...... <br /> LEACHING LINE [ ] No. of'Lines ____.__________________ Length ofeazhhne _____ " -___.._..__--_- Total Length ,.__..._ <br /> p ; a _t <br /> t 'D' Box ------------ Type rFilter, Material -- ---------------Dept hlFilter Material- ------------- - <br /> = Distance to nearest: Well ------------------------ Foundation L----_,_____._-______- Property line <br /> ---- ------------- <br /> SEEPAGE PIT [ } Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> t Water Table Depth -----------------------------------------`-------Rock Size -------------------------------- <br /> f6,6,, <br /> ft4-- ------ <br /> _ _ n _i .- <br /> Distance to nearest'Weff ________________________________________Foundation ------_-- ---- Prop. Line _.:-.-.---.._...--•-•- i <br /> t'.1tEPAIR/AD6ITION(Prev. SdnitationkkPermit# -------------------------------'.'".._ 'Date---_-_--_- --:,R----_-_-_-) <br /> Septic Tank {Specify Requirements) ' r°tir�, - ---=------------------------- ------------ <br /> - ------ -------- ------------------------------------- - + <br /> ' �p�al Field (Specify /!Requirements) e�l=/�} � a- �_y'e _-.� z�=��.c1 1 v� 1 <br /> --� _ _ .i'�s'Ftr'�✓- --._far!- x_..[.41 lam[ - ' ---- --- <br /> - <br /> ° y '(Draw existing and'required addition on reverse side) <br /> I hereby certify that It have prepared this application "c1hd that the-work-wiill be done in accordance with San Jouqu€n <br /> County Ordinances, State Lawes, and Rules and Regulations of the San Joaquin Local Health Distract. Home owner or licen- <br /> r 5�.. <br /> sed agents signature certifies the f (lowing: <br /> "I certify thin in the performance Jf the work for which this permit is issued{I:-shall not employ �y person in `such manner <br /> as to become subject to!Workman's Compensation laws of California." <br /> Signed .------ ------ --- - - ----- - - ---------------------------- ----- Owner r <br /> BY --------------------------- ---------- ----------------- ".Title'' `" - ---- - ------- <br /> (If r tlian ownerl <br /> s FOR DEPARTMENT USE ONLY <br /> t � <br /> APPLICATION ACCEPTED BY ---------A;_7 --------- --------------- DATE ..._#" y- -.3- d---------------- <br /> ------------------------------------ - - <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------= -- DA <br /> ADDITIONAL COMMENTS --------- : �r��f •" .C- '* �a 'N -"---'."'e---------=----------•---------------- <br /> =-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - ---------------------------------------------------------- ----------- ----- --- <br /> ------------�---- <br /> ---------------=------- <br /> FinalInspectionb � - ----- - ------------------------------------------------- ------------------------- ----.Date --- a ------------------•- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M y + 9 <br />