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FUR OFFICE,,USE: / +i1� APPLICATION FOR SANIi'ATi4N AERMi� / lComplete in Triplicate) P .. ermit No. .._.._ .. ......_. ..............................•-•-•- _ ........-..- x This Permit Expires 1 Year From Date Issued Date Issued .� +:........ , Application is hereby made to the San Joaquin Local Wealth District for a permit ta, construct and install the work herein described. This application Is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: .1OB ADDRE I 3 5s/LOCATION ._...--- -•- ---3.-.......2--.. .. ......__. _ �i,�.�.....................CENSUS TRACT ....:..................... 11 Owner's Name .. - .:.....................:...........................................Phone ............. . ...... ....... Address " 7"�._•�. a..S_.-._ ..! _-.City ..................... - ................ ..... Contractor's Name .................License Phone :..... Installation will serve: Residence❑Apartment House JE] Commercial❑Traller Court ❑ Motel ❑Other f { Number of living units------------- Number of bedrooms ............Garbage Grinder ............ Lot Size ...-•••........... ......................\ Water Supply: Public System and name,_.........-----------` Peat❑ rSandy Loam ❑. Cla ... .......................................... Private ❑ K Character of soil to a depth of 3 feet: Sand❑ Silt O Clay C1 Loam ❑ `�} Hardpan 0 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 aide.) ' NEW INSTALLATION: (No septic tank or seepage pit .permitted If public sewer.is,%avoilable within 200 feet,l PACKAGE TREATMENT_ { ] SEPTIC TANK f Size__. - .�>!�_ -•-•--• Liquid Depth ..'o... Capacity 1-W..... Type .. ---_--- Material_ ,ry�.------• No.� Compartments ...: Distance to nearest: Well ....,,1�f __....Foundation ..... Prop. Line _LEACHING LINE �{ j -.—Distance of Lines _j----------------. Length of each line....... ....... .... Total Length CC9 ` ' I D' Box ... ....... Type .filter Material ...1.-- _-.. . Depth .Filter Material ...��.................... ..�..... Distance to nearest: Well ---� :�....... Foundation ...� .............. Property Line '.��.Q.......... i SEEPAGE PIT ___------ Diameter ---------------- Number ..._.._......____ .......... Rock Filled Yes ❑ No O -_ { ) Depth ...'--••--- Water Table Depth ------------------------------------=............Rock Size ..................... .......... f. Distance to nearest. Well ------------------=--------------------foundation .................... Prop. Line ...................._.. i EPAIR/ADDITION(Prev. Sanitation Permit# ----------.--------- --------------_.... Date --- ............................... -x Septic Tank (Specify Requirements) --------------------........................ •-------- ........ �.. .:..._.._ . .._ . ' Disposal Field (Specify Requirements) ------------------------- # ---------------------•--•. -----------••------ (Draw existing and required addition on reverse side) - I hereby certify that 1 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 Son Joaquin Local Health.District. Horne owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall not employ any person in such manner as to becom u ct-1p Work a 's Compensa on sof California." y Signed _._.. .... . ----------------------•-•--- Owner By ......... -------- ... Witte ... --------- .------------- (I other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---••--- - ---•= ----•-•--- ------------ ----------;------.-.- ------. DATE= . .,.... :.�� ._...�..�..�: BUILDING PERMIT ISSUED _..___ -...-------.-•.----.........:.... .... .. ....... ...................... ••-----------•--•-----------DATE ....---...-.-•----•-----...._....---}••-•- ADDITIONAL COMMENTS ................ !_.....:.................... ..------•.................. :. _. .. - ---- - - - --- - Final Inspection by: . ....... - ------ ..............Date _.._. . EH 13, 2L 1-68 Rev. � ::. .... ... ._ SAN J©AQUIN L AL HEALTH DISTRICT 8/7h . 3M