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FOIL OFFICE USE: . .p APPLICATION Fdk 5AMTATION Paw A _ Permit No. ......... .......... {Complete In Triplicate} // .. ................................................... This Perm`ItExpires 1 Year From Date Issued Date Issued &7.C.`.. > 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: I1 S) l CIO\Jeg, 9A JOB ADDRESS/LOCATION. .....-- ...........�.......................--••••--....----•-••---............... .................CENSUS TRAM .................... Owner's Name r c R�`�,�`v - ._.Phone O Address -----C.C.Z --•----� ---.T--HU+32...O�............................. City .....77?2tsy................._.__-- ----.•...------...... Contractor's Name a R(��ie - License .21/ �.... Phone ...g"� .�...... Installation will serve: Residence(10 Apartment House Commercial OTrailer Court fl Motel ❑Other ...............•............................. Number of living units-1...... Number of bedrooms ____..._....Garbage Grinder ........ lot Sire ....... ...... .................... •� Water Supply: Public System and'name .7........... -------Private#a. Character of soil to a depth of 3 feet: Sand O Si'It O Clay p Peat Q Sandy loam o Clay loam ❑ Hardpan o{ . Adobe ED .Fill Material .........i.If yes,type............... .... . .... ._ -a (Plot plan, showing size of lot, location of system` in relation to wells, buildings, etc.'must be placed on reverse side:j NEW INSTALLATION: No septic tank or seepage pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK I Size---ARK!�........k-............... Liquid Depth } , Capacity 1.Zat _-.-- T -AW'4` Material_- __ No. Compartments .---.--- ............. Distance,to nearest: Well t .Foundation �U' `....:.....Prop. line 5+ LEACHING LINE ] No. of Lines ---- g `� I �g l'Z 7a .............. Length of each line...._.____.._.__............ Total Len the..-.. - ...__...._...... 'D' Box -•-- ------- Type Filter Material ....� .------.Qep#h�.Filter Material ..... ........................ Distance to nearest; Well__`....bot".......... Foundation ___. . .. ... ........ Property tine .... ................... 1k �4 SEEPAGE PIT Depth . .Number ................. .�'�_... Rock Filled Yes No Water Table Depth,"----------------------------------------------- Rock Size Y"° Distance to nearest: Well-.r...`........ ......................foundation .................. Prop. Line .-----------:-..:: REPAIR/ADDITION(Prev. Sanitation Permit ,-.:' ------ ----------------------- Date ........... .,._,:.....:.—:._�...._:.]-., .. { ' x Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) --------------- ........................................... -------------------V.,;......._..... ... ------------------------------------ ---------------------------- ; I 4. . Draw existing and required addition on reverse-We) 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, I shall not employ any persdn_ In such manner as to become subject to Workman's Com nsation laws of California." Y :'. Signed _._ -- --------- -----------•------- -------------------=--- Owner BY ------------------------------------------------ Title ..----....•. .................. ------------------------- - - - (lf other than owner) . F DsEP RTME , USE ONLY F APPLICATION ACCEPTED BY ------- ..••. -- -_. .... . --- --- --- --------;,Z-----------------DATE ///t/17F.-... BUILDING PERMITIISSUED -...---------------- ------------DATE ...--.-.-.......--..:......-..........._-.. ADDITIONALCOMMENTS ----------------------------------- - --- -------- ----•------•------.--------..-.... ----- ....................... ..............................;---------------------------------------------------------......... ----------.--------------------.-............................. -----------•-•--------- ----------------- �--I...•�. --- - ------------------------..........-..----------------------..-..------------------------ _ J Final Inspection b tom' w... =- bate EH 13 24 1-68 Rev• 5M SAN JOAQUIN LOCAL 14ALTH-DISTRICT 8/711 il3M I.