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1 - . I MI I LI L.MIIVI• 1 V1\ JMI\, II-"IVI• 1 L1111114 - Permit No. ' (Complete in Triplicate) _ Date Issued . `� 41 1.- S This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein pes%crrii(bed. This application ad in co / e with Aunty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC A c5 „ ` CENSUS TRRAACTp..... ./ ......._.. Owner's Name�°�d7 ��' /� Phone 7C -..0 Address 6 � ! iW . �.�1 City ............................. Contractor's Name r Sl��/J License #3�3 Phone. �'�OQ.7...--- Installation will serve: Residence Apartment House ❑ Commercial ❑Trailer Court Motel ❑ Other Q Number of living units: / Number of bedrooms 3 .Garbage Grinder Lot Size Water Supply: Public System and name -.. __ __.. .. .. Private (� N Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe j 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 pit permitted if public sewer is available within 200 feet,) SY t✓ PACKAGE TREATMENT [ ] SEPTIC TAIN ize } xn� � _ Liquid Depth ... _._........... ... dr' y\ Copacity�8{I� Type � Material l� ' No. Compartments ................... �r Distance to nearest. Well 'JU .Foundation /t) _. Prop. Line ... ... N! g line �� r Total Length LEACHING LINE y`L No. of Lines Length of -each 'D' Box Type Filter Material ...Depth Filter Material lB......... Distance to nearest: Well l0 .. Found?tio? Property Line .-.__........ SEEPAGE PIT Depth ZS r Diameter Numbe• ?i Rock Filled Yes No ❑ r, .Water Table Depth _._... ._._. _...... _..-.tockSize 3y' .� � Y .. 0.- PropDistance to nearest: Well �S� ...Foundation �0 h . Line 41 .-_....... REPAIR/ADDITION (Prev. Sanitatipn 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." SignedC"-Owner By Title (If other th ownerl O EPART ENT USE ONLY _ APPLICATION ACCEPTED BY � DATE O / 5 �) T r BUILDING PERMIT ISSUED / \ DATE ADDITIONAL COMMENTS l Final Inspection by: % '614- Date F/11117) SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241-'68 Rev. 5M 7/72 3 M