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FOR OFFICE USE: C sase APPLICATION FOR SA ITATION PERMIT '° � 17� (Complete in Triplicate) Permit No: ________________________ This Permit Expires 1 Year From Date Issued ©ate Issued 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: JOB ADDRESS/LOCA ION __ ,'_ It['=- ___-- / -l -��- -� '-- -.f_ Cf�75 S TRACT -------------------------- � F r G Owner's Name L172'/ 1�---- -'- e:r e- •---------------- -----------Phone ---------------•--••-•---------•---- Address -------- ---a 'f` I / I r✓-------------------------- --. City _1§14---------------------------------------------- Contractor's Name -- ------ Q_ -_ Q__ License #')_-1-5`)1___ Phone TG-fe---------- Installation will serve: Residence 94ro-artment House❑ Commercial ❑Trailer Court ;0 Motel ❑Other -------------------------------------------- Number-of living units:.___ ._ Number of b ooms Garba a Grinder Lot Size 4 r � ----------------------------------- Water Supply: Public System and name ____ __ _G�/__ ___------��`�-_____ _________ Private ❑ Character of soil to a depth of 3 feet: Sand'[] Sift❑ Gay ❑ Peat❑ Y Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe W Fill Material _/V0---- If yes,type ---------------------------- (Plot plan, showing size of loth 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 [ ] SEPTIC TANK;X Size_-- ��X. �` CJ______._.________ Liquid Depth __' ____ Capacity _____ Type -No. Compartments --- ............ N Distance to nearest: Well ------- ___-___________Foundation a Prop. Line __. f.......-- LEACHING LINE No. of Lines _ 1 Length of each line_ --------------- Total Length -------------------------- I Box ____ Type Filter Material -{ ,r------Depth Filter Material -------/J7_7 Distance to nearest: Well ___,4 _ _6_______,Foundation ____ _ __�_________ Property Line �___________._.___ . SEEPAGE PIT Depth 7 1� p -- ---�---____-- Diameter ��--____-- Number ---- ----------------------- ck Filled Yes Ids wo �[I Water Table Depth --- / •.----=`.----Rock Size -- / -Q---- --------- f .S Distance to nearest: Well ---- - __!..................Foundation _____�_______.__ Prop. Line ,,, . .......... � REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) --------------------------------------------------------- -------------------------------------------------.-.-------------- Disposal Field (Specify Requirements) ------------- -------------- '--------- ------------------------------------------------ ---•----------- -------------------------------------------- -------------- ------------------------------------------------------------------------- -------------------------------------------------------------------- (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 -------- -------------------- ��ili2�C� — ----------------------------- Title --- �1 �� ---------- ----------------- jif of than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _, --------------- DATE --3- l 7 ------ BUILDING PERMIT ISSUED . ----- ---- DATE ADDITIONALCOMMENTS ------------•------------------------ ------------------------------- ---- ----------------------------------------•---- ----------•-------------- ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- i --- -------'----- - --------------- ------ - - Final Inspection by: __ —---------------------- --- ---- ---- -------------------- ------Date ----- � ---�----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT C [> E. H. 9 1-'68 Rev. 5M