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K VJ\: ..................................................... - APPLICATION KIR SANITATION PUMIT -7S--9 _ (Complete In Triplicate) \/ Permit No. .----•-•----------.. This Permit Expires 1 Year From Dahs Issued Date Issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and Install the work heroin described. This application Is made in compliance Ith County Orrddinaance No. 549 and existing Rules and Regulationsr JOB ADDRESS/LOCA JON ,.. .. . -t,,.c..+Z :..... .......314 G_................. � .- - CENSUS TRACT . . .. DPhOwner's Name one `` Tl tyAddress c . .............................. Contractor's Name ---------------------------------------------------- ---- - -......------...-----...License # ..... .................. Phone ----•-----•---------••---•---- Installation will serve: Residence IZFI�rtmk ent Houses] Commercial ❑Trailer Court s] Motel❑Other ----------- ---- -- - ----- -------- Number of living units: ../----- Number of bedrooms Garbage Grinder ............ Lot Size ----s-'.r.49ided.4--Ze" Water Supply: Public System and name ..........------------•------------------------------____.._..........................................Private[2}� Character of soil to a depth of 3 feet: Sand[] Silt❑ Clay ❑ Peat 0; Sandy Loam s] Clay Loan Q Hardpan ❑ Adobe Q Fill Meterial ............ 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 ( ] SEPTICTANK[ ] Size.........__----------- .._. ................. Liquid Depth Capacity ........_.......... Type ----------_----_- Material. ---_- No. Compartments ................ .. Distance to nearest: Well ....................................Foundation ...................... Prop. Line .............. LEACHING LINE [ ] No. of Lines ....... ------------_-- Length of each line...................I........ Totcd Length ........................ 'D' Box ------------ Type Filter Material ....................Depth Filter Material .... ...-.................................. . Distance to nearest: Well Foundation ...-.....-__..._... Property Line ....... .................� SEEPAGE PIT [ ( Depth -- _ _ ----- .... Diameter ................ Number __._- ..._._......_ .. Rock Filled Yet ❑ No s]vr Water Table Depth --....................•---.....------------Rock Size -------------------------- 9 Distance to nearest, Well .-•--•-----•............................Foundation .................... Prop. this .........- .......... � REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................I Septic Tank [Specify Requirements) ................ _... �......... - � ,/ Di sal Field (Specify Requirementd --• ----------•-• r� . a �.... .... . - - .. - . ----- - - -- ---- ---- -------------•---•- .. --------------•--- ------ -- __.. .._.... . ...... - .... .... - ----------- (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 Ordinances, State Laws, and Rules and 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 becom subject,)o Workman' Comp ation law of California." II Signed ...w- -- --.--.. .........__---- Owner o�J By ........... ............ --------- Title --------...... 0000-- .... (If other than owner) F R DEPA TMCNT USE ONLY APPLICATION ACCEPTED BY . _4'Z6& . ... .._.. .... .............. DATE BUILDINGPERMIT ISSUED ------- . ......._. .... . . .. .......•-......... ..._ --•_....-------------. ..................DATE .. . ...................... ADDITIONALCOMMENTS ----_------------------ . -- --•--......._.................................. .......-- -------- --------- ............. _---------.- .................................................... ._..... -------••------.................-------- ................................. • ......-.............------•-•------•-•----•-----•------- ..... ............_... --- ... ... .• .................................... . ........... - ......... . ....._...._........ ... ... _. .............. ... -• . ------- - -.....-.._.----- Final Inspection by: _.... - �' _ _......Date .....//. . ?y -7s"- - ------- ..a»-,......_.------ - - . . Fat 13 2!t 1-68 Rev. 5M SAN JO QUIN LOCAL HEALTH DISTRICT 8/74 3M