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F,/,OR OFFICE USE: APPLICATION FOR SAl,11TATION PERMIT _......4SJ...-.... (.._.e' er _.. Permit No. .74....... � . (Complete in Triplicate) ,,gy�pp -- .............._• 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 Co my Ordina ce No. 549 and existing Rules and Regulations: 108 ADDRESSJLOCATIO `.. -- . •-- . ........................CENSUS TRACT ..........._._......._..... !fl /d�GL Pon Owner's Name _.... �!l�l.�... r...._...L.d✓/ __._....... •----- ................. G ff Address p��l.•...�... ------_.... City - --..._..cn4o- waw ..__........ ...... Contractor's Name ............. ............ ........................... License # .. Phone .............................. Installation will serve: Res idenceT�Apartment House❑ Commercial [-)Trailer Court ;❑ Motel ❑Other ._.... '......--------------------------...... Number of living units:.. ......... Number of bedroo s . -- K. . _Gar age Grinder •-•••••• Lot Size ......� , `�-� ---------- ----------Private Water Supply: Public System and name -----�.....-- • 1.-----r-.--_....----....._..--_•-_------__--•- •- ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay [] Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe [a"Fill Material ............ 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 tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK.11 Size._.............................................. Liquid Depth .......................... Capacity _. folB4 TYpe -•----- Material. �� 2 Jo. Compartments .. .............. Distance to nearest: Well ... _._................_.........Foundation 1605>241......... Prop. Line .c ..' . F� i LEACHING LINE [ ] No. of Lines .. ._ Length of each line...-.- 1 ._.._ .._... Total Length .-/r.t1 ............ 'D' Box ..c3 .... Type Filter Material -----Depth Filter Material _.. .. ..............._.......:._._... Distance to nearest: Well ........... Foundation Property Line ------------------- SEEPAGE PIT N -- Depth�-�`T-&.� !r—Diameter ---ZF4..... Number . ..........: .. .......... Rock Filled Yes No ] I /Water Table Depth ...........140.•------------------ -----Rock Size -------- _ P �17istancerto nearest: Well --------- ------------_--- ___Foundation ...... ------ Prop. Line ..�......7t..... REPAIR/ADDITION(Preva,Sanitation Permit# ........ ......---.......................... Date ... ------------------------ S s' Septic Tank (Specify Req'ui`ements) ... . ------------- -----------------•-------------------------------.-.-._....-•---------.-...-...-------•------------..--------------- Disposal Field !(SpecifyRequirements) ........_.. - _ � `. C (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 O-fdinance', State L'vws;and"Rules and Regulations of the San Joaquin Local Health District. Home owner or iicen- sed agents signature certifies-the following: I "I certify that in t9e performance of the wor .for hich this permit is issued' I shall not employ any person in such manner as to become ub'ect to Wor Co L e n laws of California" r I f Signed G!!L"'�^' --- ------ ---- •. ------------•---.._._..-----... Owner ,-.—By .= a.k.... ........................... ...... ...... .......... .........• Title . .... . ..... ... °-.. (if other than'owner) y i R DEPARTME19T USE ONLY _ APPLICATION ACCEPTED BY .... _......... ...... . �� . ....,. _. DATE .......f..." �"�.. ._ BUILDING PERMIT,IISSUED :....... _._..,.. -- DATE _....._..--- .....' a i. ...................... ADDITIONAL COMMENTS .�... .. ......... r �f� ...._.._ ., ............................... �/. 3 7=r/._�. -------- ........... ........................... . ....................•-. --------- . a ---- = .................... ....-- •-----....._ . V 2 Final Inspection by-...,..... ............ ....•---------. .. --- ---------------------- •-•--•--:--- Date E SAN OAQUIN LOCAL HEALTH DISTRICT "7`'172 3H