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FOR OFFICE USE: NITATION PERMIT /a APPLICATION "FOR 5A d� Permit No. ----- -----� - (Complete in Triplicate) /-.- ' Date Issued - -. - , _ This Permit Expires 1 Year From Date Issue the is hereb made"to the San Joaquin Local Health District for a Ordinance permit t and existing g Ruct and install Regulations.wooherein Applicationli ation is ivr compliance with County Ord described. This ap " , .. - CENSUS TRACT JOB ADDRESS/LOC I �. ----• - -- -�- -� - --- -•---�- -----�-------Phone ----- ----------------------------- Owner's - -- -------•---------••---- Owner's Name --- - ------- --- ----- ----------- -------- � ----- -------- City Address - - - ---- - -� - �- ----•-----•-- _ ______ - - -=-------.License # -�-- -r�--- -- Phone ---- -----------� ,� _ Contractar's Name - -- - - - - Installation will serve: Residence ❑ Apartment House❑ Commercial railer Court l0 Motel ❑Other -------------- -------------------------- Grinder --------.--- Lot Size Number of living units:---- --_--- Number of bedrooms ------------Garbage _. __,- -- . :. --Private Water Supply: Public System and name ----------- -- ❑ . ❑ k Character of soil to a depth of 3 feet: Sand'❑ _Silt ClayPeat❑ Sdndy Loam Clay Loam ❑ =gs,Hardpan ❑ Adobe'❑ Fill Material ------------ If Yes;type ------ ------ ------ -- W (Plot plan, showing size of lot, loca#ion of system in relation to wells, buildings, etc. must beplaced 200 feet)on reverse side.) i p �t permitted if public sewer is available within i i NEW INSTALLATION: '1No septic flank or seepage p P k x ------- } Size 'rn1 �C - '-------- -- --- Liquid Depth _ - PACKAGE TREATMENT [ cit I. L2�- [ , 5EP71C TANK f No. Compartments 'L.-----•----=••-- Cap y -- fyPe °�_ Material-- 1 - Pro Line F ` ------------------------` _Foundation "�-°----- ------ - P• - Distance to nearest: Well --� 0 N-P r--------- Total Length ----- - -------------- - ---�-=_'-- Length of each line--- --- -- --- LEACHING LINE [ '}�" No. of Lines ---.---- -- - D' Box - - -- Type Filter Material -?q G ----Depth Filter Material -_ k- t--------I--------- ----_-- y i � -!`�-�--------------- Foundation -�� -�--------------- Property Line.'�q_.•------------- Distance -------- ---Distance to nearest: Well. n Rock Filled Yes p� ""No i0 Depth � - Diameter of Number € SEEPAGE PIT j P _ R ---- --- ------Rotk Size -��`--------==----- - - r �r P . .� Distance to nearest: Well .-_ - Water Table Depth �{ py 9 _ -------------------Foundation --1-a.............. Prop. tine -. -----------•------ /1 - �- ----- -------- Date ---------- ---------------•-------1 REPAIR/ADDITION(Prev. Sanitation Permit# -•--- A� ---------------------------- - I xSeptic Tank (Specify Requirements) ---------------------------------------� -------------------------------------- 1. �'74 , 'Qispasal Field (Specify Requirements) ----- ------------- " ------------;--------------------------------------- ' ----------- ---- --------- yi---�'--- --------- .;: ------------------ ---"----------------------------------------------------------------- :...� �. .� w F --------- -------------------------------------------- --------------- - f �. (Draw existing and required addition on reverse si e `v= [kation and that the work will be done in accordance with San Joaquin .i hereby certify that I ha-4e prepared this app County Ordinances, State Laws, and Rules and:Regulations of the-San Joaquin Local Health District. Home owner or icen- sed agents signature certifies the following: 'I certify that in the performance of the work for which thispermit is issued, I shall not employ any person in such manner as to become sub' ct o Workman's Compensation laws of California," 7 ' Owner rSigned -------- - ----------- --- ----- -------------------- ,."', --- Title ---- --- -------------------------- --------- - --------------------------------- (if other than owner) FOR .DEPART ENT USE ONLY - i DATE --�.� ACCEPTED BY ---------'-=-----`- DATE -------------------------------------- APPLICATION ------ -------------------------------------------- ---------------------PERMIT ISSUED = ' ( ADDITIONAL COMMENTS --------- i -- ---- ----------------------------------------- ----- Date- --------------------------- Final Inspection by: -r-- - �- -�-- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 W ' 1-'68 Rev. 5M. ''