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FOR OFFICE USE: FOR OFFICE USE: <br /> r{�► PLICATI ATION PERMIT <br /> o <br /> -- <br /> .................. - ............. Permit <br /> e i rip icate) <br /> is Perini x ' es 1 Year D Date Issued <br /> .................. ........_._. ate Iss <br /> Application is hereby made to.the San Jo u' oc H ath Distr for ermit to const Ict -install the work herein described. <br /> This application i's made in compliance wit Cou y O dins and ii inti ul Regulat;o <br /> JOB ADDRESS/LOCATION c-P��p.. ;.` 'R - -- - - SUS TRACT--------------- <br /> --- - <br /> Owner's Name // - -------- ---------- <br /> ,�^-- -- -------------- hone-,? 3 S:�.a.2-5.... <br /> Address-- ..---tic -- ----- - - ------ ............... -- --....._ziP -- ----- <br /> Contractor's Name - ........... . ........ ice e #- -• - ..Phone..` _.4.............. .--- <br /> Installation will serve: ResidenceX Apartment House ❑ Co ercial ❑ T oiler Court El <br /> Motel ❑ Other -- - ---- ----------------- <br /> Number of living units:..... ...:...Number of bedrooms. Garbage Grinder--•--- - ---Lot Size--- �.- _. a <br /> Water Supply: Public System and name....:.......................... . ................. -- -------------:- •-- Private <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 INSTAL;ATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.............................. ...--- --------------Liquid Depth_'-",................ <br /> Capacity...... ... ..........Type.--------- ---- -- Material------ -----------------..No. Compartments......: -...- <br /> Distance to nearest: Well_----------------------------------- -----Foundation....- ..........Prop. Line-------_- ...........� <br /> LEACHING LINE ( } No. of Lines ------------------ Length of each line..............................Total .Length . .,------..---. <br /> 'D' Box..... -.....Type Filter Material. ................. Depth Filter Material.........---..--... ..-------------------------------- .--------. k <br /> Distance to nearest: Well----.....................---Foundation------------------------....Property Line-...----------.........__.---.----- <br /> w <br /> SEEPAGE PIT [ ] Depth....:.......'.._Did`meter---- " "-----"--Nunifjer-------------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth--------------------------- --.....------..---"--..Rock Size-_- ------. <br /> Distance to nearest: Well--------------- ------Foundation---------.---........_ .._ Prop. Line..----.------...-.-..---"- } <br /> i <br /> REPAIR/ADDITION (Prev. San i#otipn"Permit#-----------------------"---"-........ ................Date.-.--------•-----------"------.........-...... <br /> 1 <br /> Septic Tank (Specify Requirements)---._.-_..-- // /-�-------------------- - <br /> Disposal Field (Specify Requirements).--...- ....... d� � �`�--t ---- - - } �� - 1 <br /> ------------------------------------------- . ` -------------- - --•----------- .......---- - :...................... <br /> (Draw existing cind 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 i <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: I <br /> "I certify that the performance of the work for which This permit is issued, I shall not employ any person in such manner as j <br /> to become u 'e t t Workma Com . nsation laws of California." <br /> Signed_'-..-..4° -------'- - ----------- Owner <br /> B <br /> - I ...... Title <br /> -,.- .... -----`....... .......... ....... ------- <br /> By........................... <br /> (If other than own , <br /> OR EPAR ENT USE ONLY �' r <br /> APPLICATION ACCEPTED BY . . ----------- _DATE - 7 ... - I <br /> DIVISION OF LAND NUMBER......:.... ................... ........................ DATE.-.-.--. ..... . ----------- <br /> ADDITIONAL COMMENTS... ...................... ----------------- - --........._........ <br /> ----------------------------------------- --------------------------- -----------•---------- . ....----- -------..----------------- -- <br /> y rr.i <br /> �. .iF ................................ /F&S <br /> ......... ...... <br /> ----------------------------------------...---------------........._._-...-.-----------. _- ---- --------------------------------- --------------------- <br /> FinalInspection by:....--_---_- - ------- --- ---- -------- -------------- ------ -----------------------------------• ----------------.Date - ---------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 21677 REV, 7/76 3M <br /> 1 <br />