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P =OR OFFICE USE i APPLICATION FOR SAWT:ATION PERMT `!. (Complete in Triplicate) IThis Permit Expires 1 Year From Date Issued Gate Issues _( --.-_. --- 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: .• JOE ADDRESS,/tOCATlO f - __ ._ z . - � ___.-. ..... CENSUS T RACT ---_-------------------- . -_ _ Owner's Name t '--/ - - ------ ------Phone Address �' E------•_. City r v .......... �r - ~ Contractor's Name ?3 tai !�_� _ .�� I T--- ---------- -2 , -.License # J .3 _ ._ Phone ------------------------------ Installation will serve: Residence [7 Apartment House-[] Commercial ❑Trailer Court ;❑ Motel ❑ Other .-._fit- � - - ---------='-y----- Number of living units:----7...... Number of bedrooms .-------Garbage Grinder ............ Lot Size --- - -a-- - ------------- Water Supply: Public System and name ------------------------------------ -----•-------•---- ----------- --------- -----------_-----------Private Character of soil to a depth of 3 feet: Sand❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan Q Adobe ❑ 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 ifRublic sewer is available within 200 feet,), PACKAGE TREATMENT [ ] SEPTIC TANK. Size. y r� Y y Z j��—► �� < rs' f� G - -- - -...._ Liquid Depth -S ---- --- -- Capacity �-a - b Ca 6.- - _ __ �, e Material.... .._.. . _. ._- No. Compartments . _._ _ _____..__ P . Distance to nearest: Well ._-------._____-----------------Foundation .____ __.._ .. _. Prop. Line -----.--- _.____..__. .� LEACHING LINE [ ] No. of Lines Length of each line. ___._._ _ Total Length ._._--- -----------_._._. d 'D' Box ----------- Type Filter Material ..--- --- - -_---Depth Filter Material __. ------------ ------------.-----. - Distance to nearest: Well __..... Foundation Property Line ._._ SEEPAGE PIT_ [ ) Depth . .... ...... . ... Diameter _ ------ Number _ _____ Pock Filled Yes ❑ No ❑ Water Table Depth - ---------- -------------- -------Rock Size -- Distance to nearest: Well --------------- ------.............____Foundation ____ ---- - ------- Prop. Line _._.__.-_____.... - REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------.---.---------------- Date .----------.--------.------------.) Septic Tank (Specify Requirements) --- ----- ---------------- ---------------------------------------`-:--------------------------..-----------------•--------- Disposai Field (Specify Requirements) • --------------------------r--'_._. y~ - - - - - == (Draw existing and required addlition 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 Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "1 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." Signed ------ -------- Owner By ...-...... __ --- �-"" c' ...�1.. " .Title ------ ------------ - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _-�%-----=-------- - _ DATE ------------------ BUILDING ------- --- - W.. BUILDING PERMIT ISSUED - ---------- .........................DATE --_..---------•----.-- ADDITIONAL COMMENTS ------------- ----- - ----------- ------- ----- I _ - - -------- - ---------- lis -- - Final Inspection by: _:._ -- _ ........ _Date SAN JOAQUIN LOCAL HEALTH DISTRICT c i-'68 RPv SM