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(Complete in Triplicate) . .:---................. 1 This P*rmlt Expires i Year From Date Issued to Issued : FApplication 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 compliance with County Ordinance No. 549 and existing Rules and Regulations, JOB ADDRESS/LOCATION : .� CENSUS TRACT ................ Owner's Name ........... Address ................................ ......��.-... ............................... •Fhon ''::� ..... Contractor's Name City ._... •f ` .... � �.1. . .. .._.. --.:._.License 0 . ...__....,----• Phone , -............... . •--:... Installation will serve, Residence❑Apartment Hue; Commercial / �raller Court ❑ Number of living units:...... _-• Number of bedroomsre.-_-.... :_Garbo g Grinder ............ Lot Size _ Water Supply; Public System and name .._-_---•----•--_...................................Private O Character of soil to a depth of 3 feet: Sand❑ Sllt❑ Clay ❑ Peat - ❑ Sandy Loam ❑ day Loam W Hardpan❑ Adobe❑ Fill Material . ......... If yes, type tPlot plata, showing size of lot, location of system to relation to wells, buildings,NEW INSTALLATION: etc, must be laced on reverse F � , . P se sl INo septic tante or seepage pit permitted If pubic sewer Is available within 200 feet,] PACKAGE TREATMENT C ] SEPTIC TANK Size.........lt_-___•�--. .. • �..................... Liquid Depth ...�a� . t� ........... Capacity •, -- •• , Type C Moteriol....-O__a_mcI., No. Compartments � F - Distance to nearest: Well _ .. .. � .....................Foundation . - - ...... •......... Prop. Line _r.� I tEACHING LINE •_-- - -• No. of Lines .............. ........ Length of each line._..:.....�� ri •• Total Length ..... ....t��'D' Box .. .. Type F Iter Materlal� bepth Fllt Materlal ..... ................ Distance to nearest: Well .14004 .-. Foundation 'ISEEPAGE PIT ] 140 - ......... Property Line ..�.��.�...... � _ Depth ....................`. Diameter .... Number ............................ Rock Filled Yes ❑ No 10 Water Table Depth ...............................••---•.........RockSize ................................ f DistanFce to nearest: Well .__......._. Foundation p. Line .REPAIR/ADDITION{Prey. Sanitation Permit# __.........._-__••-...•_---..•...-- .........`. ....... Pro ......... ...... •------ Date ................................ .) Septic Tank {Specify Requirements] ............................. _ i Disoosal Field (Specify Requirements) .. ...- -.... ---- ........... ... ........... .............._. t .. ..............•...............•-•---=--•-•-----•-••---------•--...---•....-•----------•----------•----._.........---.......•--...................__.....---- ............ --- --------------••--•----•---- .........................................................:...._. raw existing and required addition on reverse s[de] ' I hereby certify that I have prepared this application and that the work will be done In accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homs owner or (den. sed agents signature certifies the following: ''i certify that In the performance of the work for which this permit is issued, l shat! not ` to an a$ to become blect to a m 's Com a tion laws of California.", y y person in such manner Signed gned - S .. ... - ...- �----•................ Owner litle (if other than owner] >I... .. FOR DEOARTM T ,115E ONLY APPLICATION ACCEPTED BY ........ _. .. ............... .......... : BUILDING PERMIT ISSUED .................... ... .. `' DATE . .......... . RL FADDITIONAL COMMENTS .. . . ........ .. ...DATE-.:_..... ._ a ... _......... ...... ...:_... ................... -.........ft. ........... .......... ................. .I.... ............................. ------------- - --------- -----• .................... .._.. _._..._ �G __......_.. . Final inspection b :. ...:...................... ............ Y- ------------ .------.: '� 13 2� 1—�li Rev. �f - -•--•-----........................----- Date.`....... .:. SAN JOAQUIN LOCAL HEALTH DISTRICT ..........i------- 8/7h .3M i r�