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rWK UFFICE USE: <br /> ........... ................ <br /> ---------........... aPPucar)oN FOjt saNrrArwN PERMIT ' .. <br /> (Complete in Triplicate) Permit No. <br /> . This Permit Ex Date #s <br /> ................•-•- Expires 1 Year From . .. <br /> ...:.............. m Dah issued <br /> sued P_... <br /> Application is hereby made to the Sari-Joaquin local Health District for a permit to construct and instal! <br /> the-work herein <br /> described. this application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ..-_._ .-� .-.-i•-f-...•.�.. <br /> �'. .�. •�r - <br /> �. <br /> •........_.. <br /> JOB ADQ..R..f..S.r.S...L..O...C.-.-A. TION • --1.I.•� tT <br /> ...CE.N. <br /> SUS TRACT ........Name � ... ............ <br /> .... .....:..-..-'-.. one <br /> Contractor m ................ City <br /> Or- <br /> ........................... <br /> ........... ........ <br /> ....... ..License . <br /> .._.•_.__ <br /> 0 <br /> Installation will serve: Phonee -' / <br /> Residence Apartment House 0 Commercial OTrailer Court <br /> ' . Motel Q Other <br /> Number.of living units:...,_._.- N ...---....-•--- - <br /> _�� umber of bedrooms __ ._:..._.Garbo e Grinder � <br /> Sire _ <br /> Water Su 9 �• Lot dc!f` ..... <br /> pPIY= Public System andfrtame ,••_- <br /> Char ....................................................... <br /> Private <br /> . atter of soil,to a depth of 3 feet: Sand'j] Siffi[) Ga <br /> Y ❑ Peat 0 Sandy Loam 0 Clay Loam C7 1 <br /> Hardpan <br /> D Adobe A Fill iUlaterial ............ If yea,type ' <br /> l <br /> (Plot plait, showing-size of lot, 1 cation of system.In relation to wails, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION:. r <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f l SEPTIC TANK <br /> Ca ci <br /> tet , Pa ty Liquid Depth .�1� ..........: pp <br /> ` •----- TYpe -�--�--:: Mater.ial�'•� <br /> d�r <br /> ---. No. Comp <br /> V <br /> Distance. to nearest: Well --- .- f m a .. .............. ... <br /> s f <br /> artant � <br /> 'r• r { —_- - Foundation 1.10........-.-Pro Line . <br /> LEACHING -------- ., P ' <br /> LENf:. €No. of Lines ----- Lengthe g .�. <br /> of each line:, ` Total <br /> � 1 n th ..��'._.... •Tl'l' <br /> -.. 'D' Box . _�,J�._ Type Filter Material � -�.i) <br /> ;---' _ 'f F p h Filter Material <br /> -__ _ __.. d. ..,� _-.�--- <br /> ` ys <br /> # istanc to nearest: Wel# - <br /> 6 <br /> ..._--4•*Foundation ...._... Property Lina '../V............... <br /> SEEPAGE: PITt?iarneter <br /> Depth � Number ..... <br /> -* Rock Filled. -Yes No <br /> Water Table Depth ..- -----------------..:Rock Size <br /> = ifi <br /> Distance to nearest-Well -.01 .._- ......._Foundation <br /> ---•--•----•- �---�-- Prop. Line .%���--- <br /> REPAIR ADD! .. <br /> / T10N(Frau. Sanitation Permit ..................... . ' <br /> - --------------------- Date <br /> --- <br /> Septic Tank (Specify Requirements) <br /> t <br /> Disposal Field (Specify Requirements) ......................... .._.._I..__ <br /> -- •--•--- ---- , K <br /> , <br /> ------••------• ------•. <br /> •---------- -- <br /> • _____••__ired••-_addition <br /> -----..:.---•,...__..4._............_.............•............. <br /> ' (brow existing and required addition on.reverse`side) <br /> !County hereby certify that t have prepared this applfiction and that the work will be dares in,accodance with San .fooqutn <br /> :d ag Ordinances, State Laws, and'Rules cm&Rel gufatlons of the San Joaquin Local Health.alstrict. Homo owner er#leen. <br /> sed agents signature certifies the following: <br /> "f certify that in the performance of the work foi which this permit is issued .l shall not employ an <br /> as -to become subject to Workman's Compensation laws of California." P Y Y Parson in such manner <br /> Signed ----- ••------ <br /> BY ---•-- ------------ - -- -- - ' <br /> -------------------------------------•-- Owner----- <br /> ---- ------.. Title . <br /> it er than owner! --- • -------•- <br /> R DEPARTMENT USE ONLY <br /> BUILDING PERMIT ISSUED ---------------- ` f <br /> APPLICATION ACCEPTED BY <br /> DATA :. - ... <br /> ADDITIONAL COMMENTS --._..__.- ._.._.. _ ';= ................... ------------------._._©ATE _ <br /> •----- - i <br /> --•--•-•------ ----------• -----....._._. ...----• <br /> ........... <br /> Final Inspection by: .._._. .. +.__ -.� `- ._.: _ ,.. _ ------ <br /> .__ .... .. ... <br /> Edi 13.2Rev. -� . '�...�... <br /> SAN JOA(, IN O ' L HE TH DISTRICT 8/7h 3M <br />