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FOR OFFICE USE: APPLICATION FOR SAMTATION PERMIT .:: - � Permit No: (Complete in Triplicate) � --------------------------------------------------------- /� This Permit Expires 1 Year From Date Issued Date Issued Z4_:74 7 — Application is hereby made to the San Joaquin Local Realth 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: i JOB ADDRESS/LOCATI - �t-_ --�rG /��-=(/ CENSUS TRACT ---------------------- Owner's Name '/y / -�--a------------- ------------------=---------------------------- Phone ------------------------------------ Address _.. ` dam �1 -- -dam__-?�------ City �,/ ----------------- -----------------------•--- - Contractor's Name __.-._.__L_ _-__->_- ---�. ±- .License #— __X177---- Phone Installation will serve: Residence AApartment House❑ Commercial :❑Trailer Court '❑ Motel ❑Other -------------------------------------------- Number of living units:---,---- Number of be rooms _____Garbage Grinder _—ItI"' Lot Size ___ 0___ Water Supply: Public System and name ------ - - - - ------f�.¢Ii------- -------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam Hardpan ❑ Adobe ❑ Fill Materia! - If yes,type ____________-___-___--__ `r (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) q` NEW INSTALLATION- (No septic tank or seepage pit permitted if public sew r is able within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK' �'S�-ll.v ' ____ -��'"`� [ ] ske Liquid Depth ------------------ ........ Capacity ---- --------------- Type -------------------- Material---------------------- No. Compartments -------- Distance to nearest: Wel! ------------------------------------Foundation ----------------------:Prop. Line _-__-________________ LEACHING LINE �' rV No. of Lines ......./------------- Length of each line---- ___--____-- Total Length ---e�7 e------____-- b' Sox ---- Type Filter Material !_ ___Depth Filter Material ------------------------------------ -7 __---_________________________ Distance to,nearest. Well __5 _ ........ Foundation Property Line __14------------------- SEEPAGE -----------------SEEPAGE PIT [ ] Depth --------------------- Diameter _______________ Number --------------------- ------ Rock Filled Yes ❑ No I❑ t Water Table Depth ---------------------------------------=--------Rock Size .--------------------------•--- # Distancelto nearest: Well _____.___________- _Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev..Sanitation Permit# -------------------------------------------- Date ---------------------------.------) Septic Tank (Specify Requirements) ------------------- -------------------------------------------- - -- ------- - Disposal Field (Specify Requirements) ----- _ _ _ ------f��------- __ -&w-- �-- -- ---- - ------------ ----- --------------- ------r -------------------- ------------------------ ------------------ -------------------------------------------- ------------------------- (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 become subject to Workman's Compensation laws of California." Signed ---- --- -------------------------------- Owner , By ---------------- -------- --------- Title -----e4 ---------------------------` _? (If other than owner) / FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ----------- - v Z DATE ��-c��r �� BUILDING PERMIT ISSUED -------------------- ------------------------------ DATE - ADDITIONAL COMMENTS ------------------------------- v >. ----------------- --------- ------------------------------------------------------------- ------ - - - --------------------- --------------------------------------•- ------------------- --------------------------------- ----------------------------------------------------------------- ---- Final Inspection b _.____.______Date -. �__ __ a SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. "u&