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:ori pl'ete !n "'rlpficatel <br /> . rhis rrarmit Expires t Year From Data Iscue-d Date !!sued ...:.:...... .:. <br /> r., erWe raby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> oll <br /> described. Thi pp on Is made In compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> 53 an ' � !� <br /> ON �t....:%� -i4..: �::......................................- ....`.. ..CENSUS TRACT .......................... <br /> Owner's Nome is r /. ; .. ,r :fi:.: ............. _.. .._.... �..... - •T Phone _............. <br /> lr .:.sem.. - .. -... <br /> Address ----. .'.`4!..... _ .. . `._1-1...... ---------- --------------------------City ...Z................................ ....... <br /> � l F <br /> Contractor's Name `' -........ <br /> ------•---• �F..__ - _ ` �~ - License ..--- -'-.. "'. _ Phone :. ....__. z" <br /> Installation will serve: Residence[jkp,artment House(] Commercial ❑Trailer Court i] <br /> Motel ❑Other----------•------------------------------- <br /> Number of living units:-_._ --- Number of bedrooms ____Garbage Grinder ------------ Lot Size _..��--�--�_---------__---•-- <br /> Water Supply: Public System and name - w._ _.__.____..___------.._----_----_.._.___Privated <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ . 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 [ J SEPTIC TANK f; ;. Slze_� . . . .. `!V-_____________ Liquid Depth ....: �.....__._�._. <br /> Ca acs Type ------------ Material__.................. No. Compartments - <br /> Distance to nearest: Well _ ------------ - re - <br /> ______Foundation ._ ___......__...._. Prop. Line _ <br /> LEACHING LINE <br /> [t4--"No. of Llnes� ............ Length of each.line _ 'y V�.}_ Total Length 'T.'j`�`.: <br /> 'D' -------------- , a th Filter Material ..._.. . .............__... <br /> Box Type Filter Material � p 4 <br /> Distance to nearest: Well .......... Foundation ................... Property Line ------- <br /> SEEPAGE PIT O Depth -------------------- Diameter -------------_- Number ....................... Rock Filled Yes ❑ No Q <br /> Water Table Depth - <br /> - --•----------•------------------_.__.._.:__.Rock Size _...::.._..__.......---•--..... � <br /> Distance to nearest:Well .:_..___......Foundation -...............�. Prop. Une _._._....._. <br /> ` ---- ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---•-------------------------------------- Date ................ <br /> Septic Tank (Specify Requirements) --------------------------------.----- -----------•----------------....__._.................... ................... <br /> .._....� <br /> DisposalField (Specify Requirements) _....._.._.._---------------......._..................--................_.................._............-------_............ <br /> ..••................•----..-..------•----.._...__._..._..--••--•-•-•----•------.....-----...._._......_......__..... ..... . . . .... <br /> ............................................_.._..............-.........-•--•---..._. ---•---- •• <br /> - -- -._._...••--- ----•---•--• ----•----- <br /> . - - _ ._..._ <br /> (Draw existing and require.. d addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health Disirid. !Torre owner or (icen- <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 /> s mpensation laws of California." <br /> as to becom s b-eN btW-`-tm�an so <br /> s1 t <br /> Signed _�.._._._ __.._....._... Owner v <br /> - ..... <br /> ,f .�, . title i- " <br /> ...... <br /> By •.....................................•--. ............::._.....-- -- - <br /> Of other than owners <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY .................•-•-----...-•--------•----•--------•----....--•-•---....... .... .yf...... DATE ...4 -� �....._.._....... <br /> BUILDING PERMIT ISSUED ................................._............._...•-----•----•. ...---.-- ....................... <br /> ........................................... <br /> ADDITIONALCOMMENTS ------•--------•-----.............................-----------------------------------------------------------------------------a............................ <br /> -•-•-------•---•------••------•-•-•-----•--....-•------ ........................................................... •--••-......._..-.....-----•------..............:_•--•--....---•..__.._..--•----- <br /> -•-••-------•-•••--------•---•--•--- ----------------••-•---•----•...-•---.....-------•----•-•--•---•---•-•-•------ ----------•-------._..._................------••-••-----....-----•-----------..._..... <br /> .............._................... .........••--- -----------------••-•------•------••-----------------•---•-----••... .- ----••----••------ -----•------.._...--------....-••-••--........----- <br /> Final Inspection by: ................................... -............................................. <br /> . ..............Date ...../d-a ......-•--•-•--• <br /> EH 13 2a 1-68 Rev. 94 SAN JOAQUIN LOCA HEALTH DISTRICT 6/7h 3M <br /> This is a Cory 0-f -see at4mer r Cory 0-f fie perou <br />