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FOR OFFICE SE: • p MP UCAVIOM MR SARl1TATIOM Pic=BF // ICocapfota tm�Yeipilcarol Permit No. ...1.�-T;r yell..................................... .... This Porm t Expiroa 1 Yoar Frora Octo IBcuod Date Issued ZZ. 2&...f Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal) tho described. This application is made /i�n compliance /winty Ordinancep No. 549 aril xisting 13 f nd R JOB ADDRESS/LOCATIOPM(- l7`,� .�/ ............ :..,...-�� wjo't�lon� t .............CEN TRACT Owner's Name - - ._...........................•----...................•.Phone ... 19P:. ,1'1.----- Address ............... ?.. city _ . Contractor's Name. ..k_ ---..--.. .o .... ..License 0 ........................ Phone Installation will serve: Residence Apartment Hous©fl Commercial OTrailcr Court MotelQ Other...... .................................. Number of living units:----- --•-•- Number of bedrooms--3�......Garbage Grinder ............ Lot Size .:................ Water Supply: Public System and name ..............................--._..........................................................................Prlvato� Character of soil to a depth of 3 feet: Sand b Silt o Clay Q Peat❑ Sandy Loam [] day Loam 2C Hardpan Adob*VT Fill Motorial............If yes,typo........................... (Plot plan, showing size of lot, location of system in rotation to wells, buildings, ate. must bo placcd on rovorco sido.j NEW INSTALLATIOW: (No septic tank or seepage pit permitted if public sewer is available within 200 feat] PACKAGE TREATMENT ( ] SEPTIC TANK fj Size................................................ Liquid Depth ........._........ . --�► capacity T Material...................... No. Compartments X Distance to nearest: Well .---•...............................Foundation...................... Prop. Lina ..................... LEACHING LINE ( j No. of Lines ........................ Length of each line.............................. Total Length ............................ to V Box ............ Type Filter Material ....................Depth .Filter Material ............................................ - Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT [ ] Depth Diameter ................ Number ............................ Rock Filled Yes © No 0 Water Table Depth ................................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Lino ...................... 1REPAM/ADDITION(Prov. Sanitation Permit# ............................................ Date ----------•----.--------..-------.j / Septic Tank (Specify Requirements) ...._�oS ..... ........ ..................... ........... 4 -.... .-........--.-........_....,......._................. Disposal Field (Specify R irements) -• •- __ ...- ........ .......•--•----... . ..� .� U ! .. . n ...............•. x � ,.. �-=...... .. �c..�.s: ' /�-�......•-•- -•• ...................... ...............--•---.................. . (Draw existing and required addition on reverse side) I horoby certify that I havo prepared this application and that tato harts will bo dorso In caccomaasaco aA►Itb 2--1 JQgein County Ordinancoo, State Laws, and Rules and Regulations of the San Joaquin Lecml HeaMh:©istrid. Monro ovA—,-7 or Ilcoc.- sod agents signature certifios tho following: "I certify that in the p once of the work for which tb s it is Issued, 1 shalt not oaroploy any person to saxh mangy as to boco subje an's ponsat n lags o Co amlo. Signed . L -..t. ... �- �/ %- .4 By---------------- ------------------------------------- --------------•----- f_. Title dLCt...-. --------•-•-- .--.-----------------•----•-- (if other than owner) / FOR DEPARTMENT Ul§ ONLY APPLICATION ACCEPTED BY v.._............................. DATE ... .---- .._..� •--- 7K�_..-..._ BUILDINGPERMIT ISSUED ..................................•-•-•--..................,�_....----•-•-••••-•....__....__...........DATE ........................................... ADDITIONALCOMMENTS .........................................•--•--------------•-••---_...........---.._......----•----.........._...._.._...._....._.:::...._................_.._ ....................•.. ......................................................................... ........,......................................-...................................................... ..................................................................... .. .._... ---------_....._..........•-----................_....---••---•..........._....._..........I--•---------•..---...... ......-- •-- •••--• •--• -- -- •- Final inspection by: .. Date ... _:.�Q. .. �iW.................... EH 13 2!i 1-6t3 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3H