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FOR OFFICE USE:: ............. �Gr . - APPLICATION mF0 R nANIpTAp�ON PERMIT Permit No. .. .. .` , f`... - Z Date Issued ....................... '......._.:..................... This Permit Expires 1 Year from Onto Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein described. This application is made in compliclnc with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ../, 7F .... �o .....................CENSUS TRACT ............,..... ....... Owner's Name ...... . .....................................,........... Y..... ....... ...Phone .,....... ......; ........ Address . . ..___ ..5....r�. ... r-..:.. �.�7 City Contractor's Name ---.-�... -- ...•...............License # s .7��.7.. .. Phone Installation.W-ill serve: Residence ❑Apartment House 0 Commercial ❑Trailer Court 0 Motel ❑Other F rr�� r. Number''of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size sem . _...._...._.. Water Supply: Public System and name .........:...... ..Private I Character of soil to a depth of 3 feet: Sand❑ Silt Clay ❑ Peat❑ Sandy LoamZ ' Clay Loom ❑ Hardpan ❑ Adobe 0 Fill Material ............ If yes,type ............... ............ (Plot plan, showingsize of lot, location of system in relation t y o wells; buildings, etc. must be placed on reverse aide.( NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Ra PACKAGE TREATMENT f SEPTIC TANK Se�ize.. ..�� ..,11........... Liquid Depth ..,� ��...........:.. Ca actL Type Y','1;ci�. Material..�t�.i'1J e:J. No. Compartments ..c�--.............. p tY L/� Distance. to nea est: Well ...._�'s�. -------- Foundation .... Prop. Line ... -00 LEACHING LINE [ ] No. of Lines -----/-- Length of each line..-,. Q. ��... Total Length ...g4 . ..s....._... J D' Box .. ..... Type Filter'Material (. ��. 1. �6epth Filter Material .....�4i. 1�.'................____.._.. 6 Distance to nearest: Well .. 44 P1_ _. Foundation ...... Property Line _&#- ".....•.• � SEEPAGE PIT [ 1 Depth ----_---------_.. Diameter -------........ Number --------------............-- Rock Filled Yes ❑ No ❑ Tn i Water Table'Depth --------------•........------------------------.Rock Size ...:------•----•-•••----•........ ' f Distance to nearest: Well .................................:......Foundation .................... Prop. Line ...................... . -"RI'PAltt/ADDITION f Prev. Sanitation Permit+# ------------------------•----------......... pate .................-•--••---------_-1 Septic Tank (Specify Requirements). ....-------------------------------------------------------.............................................. .._.... DisposalField (Specify Requirements) -------------------------------------------•---•------ ..............=...................-.......................................... --------------------- ----------------. ..---------------•-------------------------------------------- •----------------------------------------------------- -------•-----------------------------•-----•--......... ------------------- ---...---............------..........................•-•-•-. f 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 San Joaquin Local Health,District. Name owner or licen- sed agents signature certifies the following: f "I certify that. in the performance of the work for which this permit is issued, I shat],not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed . � f --------- -- ---- -------- ...... ------ ---- - Owner � - By � ------------ Title'- � .. (If other than ow } F R M#R MENT .UILE ONLY j APPLICATION ACCEPTED BY -r l - -•--- ----- . DATA BUILDINGPERMIT...ISSUED------ ............ ----------------------------•---------------.--------- -.- ----------......DATE ..................................---•---- ADDITIONAL COMMENTS -•-------•-- ------ -------•--_-- - -------------------•- ----• --------- - ----- ...........................•-• ....------------......._.. ..........-.. ...........................•---•.-..---------------_--- ....... Final Inspection by: - Date .. :.�!:I—: .. .--- EH 13 2b 1--68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M r - - r