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FOR OFFICE USE: �_ - APPLICATION FOR ITA 0 PERMIT � ' �� C c�sy./ rr T" .PERMIT in Triplicate) Permit No. --------------------------- -------------------------- This Permit Expires 1 Year From Date Issued 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 ADDRESSAOCATI N ! D-------� f J- `'" -----------------------------CENSUS TACT ... .... ............. r Owner's Name -------�kw l�' �' 'v----------------------- ------------------------------------Phone ----------------------------------- Address ------------------------a- -..��- �L ---�/-G-`-�-�' City -�iPC -`�------ ----------------------------------- Contractor's ---- _ - -- - -- --- ---- - Contractor's Name ------- -o-�--------� �__-�-------------------------------License # ��z-�� Phdnels - f _--- Installation will serve: Residence`A Apartment House❑ Commercial ❑Trailer Court ;❑ i ' ! Motel F1 Other -------------------------------------------- gg; Number of living units:___!------ Number of bedrooms ___Z____Garbage Grinder ------------ Lot Size ____________ Water Supply: Public System and name l �_____ � �'1 ___ �r ---------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material ------------ If yes, type --------------------------- (Plot _____________________ _(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATIONa {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ` �■ PACKAGE TREATMENT [ I SEPTIC TANKSize__J�?_ _ ~__________________ Liquid Depth D "�--- ------ Capacity____-_- Type '_ Material No. Compartments --�.............. Distance to nearest: Well-r-1-------- . _�________ Prop. Line �'r�____�________ LEACHING LINE No. of Lines ____/__________ ____ Length of each line-_Z�p�-------- Total Length / �.__.........__.. 'D' Box -- �� Box/VP-- Type Filter,�Material �!�Depth Filter Material/��_________ __ ______ Distance to nearest: Well __-...!�___ Foundation __011- Property Line -- --_to SEEPAGE PIT ( Depth --- Diameter DiameterNumber _________ Rock Filled Yes " No Water Table Depth _____ 4P 7------------------------------ Size�"---o"-TK-- -------- s .01 f= Distance to nearest: Well ----------------------------------------Foundations--- Q______ Prop. Line -a;-~-_____-_____ REPAIR./ADDITION(Prev. Sanitation Permit# ____________________________________________ Date __________________________________) Septic Tank (SpecifyRequirements) ---------------------------------------------------------------------------------- ------------------------------------- f Disposal Field (Specify Requirements) ____________ -__--_-----------------------------__- "'------..•---------------------------------------4----------------- 4 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --------------------- ------- - ------------- -- - --- - Owner BY ------- --------------- Title - ---------------------- - `-� �a -'----------------------- (If of an owner) 1. FOR DEPARTMENT USE ONLY APPLICATION X CCEPTED BY ------ DATE _ �.1•�6.. ---71------ BUILDING PERMIT ISSUED ------------------------------ --- --- -- ------------------ ----- -----DATE ------ -----•--------------------------- ADDITIONAL COMMENTS -------------------------------------------------------------------------- ---- ----------- -----------------------------------------------------_---------------------------------------------------------------------------------------------------------------------------------- --- ----- --------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ - - ----------------------------------- -- ------------ ---------- - - -------- ---------------- - - - - - - - - ------- - Final Inspection b ` � - __- p Y� ----- -------- - ---- -- ----El"-Y --�--f-�___---_ ----�------------- ---- -- --------------------------Date -./ - -- -- ------ SAN JO\AQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ■