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FOR OFFICE USE: ...... ..... ... APPLICATION FOR smimrm mw ........... (Complete in Triplicate} Permit No. z ...... ............ ...... This Permit Expires I Your From bete Issued Date Issued, �'•,M:J c Application is hereby made to the San Joaquin Local Health District for a Permit to construct and install the work horelln described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations, JOB ADDRESS/Lb TION o2,.r1trA0__ ......... ........ _e .... CENSUS TRACT A.47 .......... Cwner's Name &a44-1411—An ....... . ...................."> .............. ..... -phone .. . ... ..................W. ,..._ Address Contractor's Name ....... city _49A�o .. ..... . ......... . __ ............ . ..... ------ *-'-'**** .............. ....License # Phone ......... Installation will serve: Residence Efl Apartment House 0 Commercial C]Traller Court C] Motel 0 Other ............ ................. Number of living units:_.. Number of bedrooms ............ Garbage Grinder ....... Lot Size Water Supply., Public System and name _ ....... ...................»,......_....._._ ...... ------.._.._...:.._.._......,__..---_,...._..,__Private ❑ Character Of soil to depth of 3 feet. Sando SijtC] C10YE3 PeatO Sandy Loam .o ClayLoarno Hardpan r-1 -Adobe 0 fill Material ... 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 it permitted if public sewer is available within 200 feetj PACKAGE TREATMENT SEPTIC TANK........ . . ...... .. Liquid Depth I Capacity Typer" Mat*ri0Vt0y-'--0-_ No. Compartments 0 N-1 Distance to nearest. Well 1 11 LEACHING LINE I [X t ... .... ...... . FMHAWJ�" ... I 4� ----- Prop. Line ------ No. of Lines Length of each fins Total Length I), Box Type Filter Material ....... Depth Filter Material Distance to nearest: Well A.Q. ' 0 ' _t ......... Foundation Property Line -11;- ........... SEEPAGE PIT /U Depth _:4�r 5 .......... Diameter ... Number ....... Rack Ffllod Yes NO)o Water Table Depth .... I. ."... ... I _ ... .... ............ .,,..........Rock Size-) ��A ................. Distance to nearest: Well / 11�01 r.# . . ........... Foundation .... . Prop. Line ......... REPAIR/ADDITION (Prev, Sanitation Permit # .... ... I . .. . ................. Septic Tank (Specify Requirements) ............' ... Date ................. ---------------- .. __ ........ .. Disposal Field (Specify Requirements) ..... ............ ............ ........ . . . . ........... .... . .... ...... .................... ......... .... .. .... . ... . .... .. .... . ... ...... . ......... ................... — ...... .. ........Draw existing and reqvired addition on reverse side) ..;0....... I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin I County Ordinances, State Laws, and Rules and ft"ula s otho Son Joaquin Local Health District. He licen- sed agents signature certifies the following. tW"f me owiter or I con- ") certify fhf in the performance of the work far which this permit is issued, I shall not amOlOY am Person in such manner as to beql�' abie to a.*- 4dW taws Of r Signed Owner By .. ....... ........ . ......Title ....... (if other than owner) DEPAATMCTMENT USE ONLY ACCEPTED BY APPLICATION ACCEPTED BY...e. BUILDING PERMIT ISSUSD., ...... . ....... — ........... ........... . .......... DATE 704 _DATE ADDITIONAL COMMENTS ....... ....... ------ * - - ---...-»,.»__, --- - *"*"'*"'____ ..................... ....... ................ ......... ................. ------------------- .............. .. . ...... . . ...... ...... .......... Final i ------- -------------- - --------- * - ------------ ----- .............. --1-- . ........ ---11.- ............ Cate. SAN JOAQUIN LOCAL HEALTH DISTRICT ,E. H. 9 1-'d8 Rev. 5M