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FOR OFFICE USE: a - / .y !... /1.7��..-•_-- -Z.° .._. APPLICATION FOR SAMT -YION�PERMIT 1 (Complete In Triplicate) Permit No. .. ........................... d.. ••---•-". This Permit Expires 1 Year From Date Issued . - . ' " Dote Issued �6,•-�• Application is hereby made to the-Sun 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: i` JOB ADDRESS/LOCATION .../w2.9�g.__-„�ty- .-z ._r( .. . . . , ' _... ...... - _.>�_.,...._...... .........CE/NS US T RACTOwner's Name ..--- � ..._. � 1 ...------Phonems !•..�....•."....�... te..t....................Address ZkZza--._ ............... ............... .... city _..Contractor's Name T� .....................•---•........................ ------------------------ --------------- ----..License # ....................I... Phone ........ ... Installation will serve: Residence ,C-.,` ompartment House 0 Commercial ❑Trailer Court ❑ . Motel ❑ Other........ Number of living units:............ Number of bedrooms .. .....Garbage Grinder .../k°-P--- Lot Sire --------------•------ Water Supply.I Public System and name ....... Private ❑ Character of soil to a depth of 3 feet: Sand'[]' . SiltCla ❑ Y Q" Peat O" Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe :❑ Fill Material ............ If yes,type .............. 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on side. NEW INSTALLATION: ) (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK SiSize---------------- Liquid Depth N Capacity -------- Type .................... Material..-•............ ........... --• No. Compartments 9 ............. ....... Distance to nearest:,Well Foundation ...................... Prop. line _-•-- 1 LEACHING LINE } -•---•....I.--... [ ) No. of Lines ------ Length of each line..------_• o........... Total Len th - --- t'D' Box ----------- Type Filter Material "P4L..Depth Filter- L r �! In Distance to nearesh Well ..•• foundation Mdtena ------------------- -----. -"------•---_• --------- - ---- . ' ••-'-" ••... Property Line - r ------------------------ SEEPAGE PIT - " � •---•-•-•-•--.....__.--• y p [ j Depth Diameter Number . •••...---•-•---- .... Rock Filled Yes ❑ No Water-Table Depth Rock Size ................. ------...---•-- Distance to nearest: Well -------________ __ !b Foundation Prop. Lina ......... ... l REPAIR/ADDITION(Prey. Sonitation'Permit�# ...............•_.- - •.................... Date ---:.......__.: , Septic Tank (Specify Requirements) .1................... y ---- --•------*.......--•------------------ -------•---•-----.._........ Disposal Field (Specify Requirements) _ �f "" C 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: r "I certify that in the '��. performance of the work for which this permit it issued, 1-shall not employ any person in such manner as to become subject to Workman's Compensatldn laws of-n alifOrnfa." •' " _ Signed . - ------ . Owner - - -...":.-.-..------••-------•-------:..-----••-----••----- Title _. (If other than owner) ) �� ............ ... . FOR DEPARTMENT�USEONLY APPLICATION ACCEPTED BY_ BUILDING PERMIT ISSUED ,.................. ...... .... ... w DATE ADDITIONAL COMMENTS -- DATE ....---••- ..... .............................. • -- - ---------- Final Inspection .. .......................................Date .... i... �v __. .... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 24 1_'68 Rev. 5M