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FOR OFFICE'.-US5:' APPLICATION FOR SANIiXTION PERMIT .0 (Complete in Triplicate) Permit No. 1:---t-71. ------------------------------------ Date Issued z-_- -7 ------- ----------- This Permit Expires 1 Yeeir From Date Issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in coT. pliance. with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION CENSUS TRACT -------------------------- ;1/__!_/Z_:i ------------ - Owner's Name -------- -- ---------------------------------------------I------------ -i---Phone ------ - --------------------- ----- --- ----- ------------- Address ------ City -------- -- ------- -- Contractor's Name ..../4 %-------------------License J --- ---- -- 4 Phone --------------------- Installation will serve: Residence P-g-P-0–r—iment House-E] Commercial :E]Trailer Court ;El Motel E-] Other Number of living units:____ Number of roo s arba-ge Grinder Lot size I -------------- Water Supply: Public System and name ------4; - -- - ------ ------ rT7TT% ________-_Private�1 , -% ----LE4--- 11 4 Character of soil to a depth of 3jeet, Sand❑ Silt Clay E] Peat E] Sandy Loam Clay Loam F-1 Hardpan E] Adobe Fill MaterialIV_19 If yes,type ---- ----------------------- (Plot plan, showing size of lot, location of system in, relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic-Gm see 'a6e 1:74 p�irmitteclIif public sewer is6va'(Gblev�itgin 200 feet,' CT PACKAGE TREATMENT SEPTI AN Liquid Depth Capacity Compartments 0. ...... Type ----AL__;M�t�e __o ------------- Distance to nearest: Well ----------- ------------- ----Foundation/Zy-------------- Prop. Line - -----------7------ .'I. , i---------- LEACHING LINE No. of Lines ------/--------------- Length of ecA7'I"!ne__'/_'0d------- ------ Total Length ---Type-Fi Iter-Materia I __ _1C_ ___Depth Filter Material ---------------------------- R Distance to nearest. Well ----- ------------ Foundation _ Q________________ Property Line SEEPAGE PIT/!, Depth 1______ Diameter _-2.-L Number ---------I----------------- Rock Filled Ye 00 Water Table Depth ------fes,----------------- 1 ------------Rock Size ----U/0---------------------- f Distance to nearest: Well _________•`r---------------_--Foundation ------- Prop. Line ---------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- "Date -------------------------- Septic Tank (Specify Requirements) -------- ----------- ------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) -------------------------- ............................... ---------------------L ---------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------:---- ------------ -------------------------------------------------------------------------------------- -- -------------------- --------------------- (Draw existing and required addition on reverse side) I hereby certify thit I have prepared_. this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, andRulesand 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 person in such manner as to become subject to Workman's Compensation laws of California." t Signed --- ----------------!- --- ------------------- Own ByBy ---------------------------'------ ---- —------------------- (If oth'erh�a owner) I FOR RTMENT USE ONLY APPLICATION ACCEPTED BY----------- DATE Z - ------------------------------------------------- ------ BUILDING PERMIT ISSUED -- -- -- ------------------ ------------- -- - ---DATE -------- -- --- ------------------------- AD---D--I-T--I-O---N---A-----L------C---O--M---M----E-- N---T--S --- ---------------------------------------------------------------------------------------------------- ---- -- ------ -- - ------- -- -- --- -- ------ - - ----------- - ----------------------------------------------------------------------_--7-------------------------------------------------------------------------------------------------------------------------------------------------------------------Final Inspection by: ------- Date ------V---------------- - r AN JOAQUIN LOCAL HEALTH DISTRICT --------------------- - - ---- E. H. 9 1-'68 Rev. 5M