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` mrrw%*meiwir rwK r"CrCrtl'tir �._,..,.' .... (Complete in Triplicate! Permit N. . ...77....`� / ' This PeirlC @xpie®$ 9 Year From Oats Issued Dote Issued Application Is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein L.! described. This application is made In compliance �with County Ordinance No. 549 and existing Rules and Regulationse JOB ADDRESS/l TION .. �'.. .. e..,�� ............................. CENsuS TRACT ...... ............. Owner's Name ....�C1...r ..........................I.. . . . . .........I.............. ... ...................................Phone ..�. -'d. ....... Address .J? ..... . -- --..!' '..............................City ..... ......... ............. .............. _............... ..... Contractor's Name ..... .... ,... ...:...................License .,.' .... Phone .. :�1f............J.. Installation will server a dente U-Apartment House❑ Commercial(]Trailer Court ❑ Motel 0 Other----------•---------- ------•---- ......... Number of living units:............ Number of bedrooms ..'l....Garbage Grinder ............ Lot Size ..._.:................_..................... �^ Water Supply: Public Systerfi and name ....................................•------•--•-------•-........_...........................................Private b Character of soil to a depth of 3 feat:' Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ Hardpan❑ Adobe❑ Fill Materlal ........... 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 INSTALLAYIONr (No-eptic tank or seepage pit permitted If public sewer is available within 204 feet,l c I C PACKAGE TREATMENT .{ ] SEPTIC TANK, Size................................................ Liquid Depth .......................... . i -' Capacity�..Z��........... ype .. ......... .. Materlal...................... No. Compartments ...... ...,. _ Distance to nearest: Well 1,4ye.._ ....._-.Foundation /p .... Prop. Line LEACHING LINE [ D No. of Lines .6.................. Length of each line..2d................... Total Length :2,2a.............}.� 'D' Box I-__- Type filter Material.. ..._Depth Filter Material .............................. ..U1 Distance to nearest.• Well . ..................•-- Foundation ........................ Property Line .......... .......... . N SEEPS PIT [ Depth .................... Diameter ................ Number _-_,_-_-_-_-_-_-:___--._.:_. Rock Filled Yes ❑: No OV Water Table Depth .Rock Size � Distance to nearest, Well ........................................Foundation .................. Pro Una ................. ..... , lI:EPAIR/ADDITION(Prey. Sanitation Permit --- Date ) (p : Septic Tank (Specify Requirements) ......................................... ..................................... .......... .._.... ,......................... ..� Disposal Field (Specify Requirements) .................................................... F---•---------•-'-"--'-•-----•••-•---•.^••-----------------•--•--•---------..........._-•------•-•-`-••........._-----•----•-•-•-----•.................. ........_.... - •• - ..._.----•......................... ...........---.................__......._..._...._.....................--...... --._....•---...........------................` (Draw existing and required addition on reverse side) . I hereby certify that I have prepared this application and that the work will he done In accordance with San Joaquin { F, County Ordinances, State Laws, and Rules and Regulations of the Sart Joaquin Local Health District. Home owner or Rcen- L . "— sed agents signature certifies the following: "I certify that In the performance of the-work'for.which this peiinit Is Issued, I shall not employ aey persons in such manner I as to become subject to WorkmaWt Compensation.laws of Colifornia; u l signed ... ••-•••.. - �- ..':.� ..-•---•----•-•...............•---............._... _ Owner 8 ....... --- ............. ........................... -•--•-•- - Title ........................... -----...._ ................................ (If other than owner) .•t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... `O- _ . .. ......................... DATE . BUILDING' PERMIT ISSUED .................. .....DATE ..... .. : ADDITIONAL COMMENTS -- ------ ............................:......-.................--. .............•--------••. ....-• . -.............----•.--.....--••--•--•..... .......---.....--..-..... ....----........................---. . .------...-----.... .. . --•--- ---------- ---- -----•---- ------ ...-..... ......................... ... ... -. ----- ---..... _ Final Inspection fay: ..............................Date ..ci� ............... ,I Ell 13 2h 1-68 Rev. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT S/Ili 3M