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FOR OFFICE USE: APPLICATION FOR SAMTATION PERMIT ° Permit No. -------- ------------ ------------------- --------------- ,)Complete in Triplicate) -- - ------------- --------------- -------------- Date Issued 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 des&ibed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: - r ------ " CENSUS JOB ADDRESS/LOCATION T w�- -------.-Phone---------------------•------ Owner's Name ------ Address Q «-- ------------------------------- ---------- • City Xllt �L'�CLr ----------r------------•--------s Address __� '�''�'! '� p � - ' Contractors Name ._ r -�_JLe :.�_.License # ,a -a __ Phone -- --; -- - CG' Installation will serve: Residence- Apartment House Commercial ❑Trailer Court . ❑Other °--------------------- -------------------- Motel4 t Number of living units.-- -----.- Number 'bf bedrooms - Garbage Grinder--, --._:.-Lot Size--:-- _ _____ Water Supply: Public System and name __________ Cls Peat Sandy-loam Adobe Fill Material .N_(!__ if yes, typ ❑ Clay Lodm :❑ Character of soil to a depth of 3 feet: Sand" J Silt❑ y ❑ ❑ ; Hardpan ❑ ❑ e = Plot Ian, showing size of lot, location of syste in relation to wells, buildings, etc. must= be placed on reverse aside.} r„ ( p II �W3----e-- �. NEW',INSTALLATION: (No septic= NKi p Size_____ XIQ-- - Liquid`'Depth ,--- --- ' tank or see ge pit permitted if Ublic sewer is available within 200 feet !/ PACKAGE TREATMENT { ] SEPTIC TA [ J ` Material____ u%.,Oo;/Compartments ---------A Cosaty - -=---- i `c2�-O--------- Type `° , ' �- -Q ------- Pro �ine stance to nearest: Well __--_ ___3------ Foundation t ------ - LEACHING LINE /- No. of L' es -------� -------- Length of each Iine �� ---- r - Total Length b----------- 'D' Box 0 - Type Filter Material ---------Depth Filter Materia! ----3d- _________ � - -- i Ce � { to nearest: Well ___ TFoundation __� --' �--- Property Line ---- --••-----._..• R E J C l Depth `- _--------------- Diameter ---------------- Number Rock Filled Yes SEEPAGE PIT ❑ No I❑ i Water Table Depth (.------------- - -----------':.------- a -------- Foundation Prop Line f Distance to nearest: Well _ i 'a ------------------ Date ---------------=------------------} i REPAIR/ADDITION(Prev.(PreySanitation Permit# ____-__..______----___-- t ---------------- --•-----1--------------------- Septic Tank (Specify Requirements __________________..___--- ----------------------------------- Disposal Field (Specify Requirements) ------------ ------- g==: _. — ------------------------------------- ------ ------------ -------------- ' I (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. Nome owner or licen- sed agents signature certifies the following: l i "I certify that in the performance I of the work for which this permit is issued, I shall not employ any person in such manner I, as to become subject to Workman's Compensation laws of California." ` Signed -- ---------------------------------------I- - -------------------------------------------------- Owner By --/,// - I Title ----------- ---- ---------------------------- '41 (If other than o ner} FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY i -c_Q---------------------------------------------------------------------------- DATE �� I BUILDING PERMIT ISSUED -------->`------------ ------------------ -----------------------------DATE ------- ------------------------- -- ------------------------- ADDITIONAL COMMENTS ----- --- ----------------------- --------=---------------------------------- ------------- ----------------- -------------------------- ----------------- ._. ---- --------- ---- --- - -- - ----------------- - --------- ------- - _ -•--- ---- -- --------------------------------------------- Final Inspection : -_ ----Date i SAN .JOAQUIN LOCAL HEALTH'DISTRICT To ( E. H. 9 1-'6$ Rev. 5M.