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F � OFFICE USE: --------------/----------------------- ------- ------ )PLICATION FOR saNrrarroN PER r (Complete in Triplicate) Permit No: -�_("=-- -- a This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and660 described. This application is made in compliance with County Ordinance No. 549 and existing p i ern JOB ADDRESS/LOCATI r f ON { " l' }tiara CENSUS TRACT Owner's Name t� ..f r - ----------- ----------------- ------- -------------..------ ----- - ---P one�-- -------- --- ' '- ----- _._. city ------------------------------ Contractor's --- Name __- - '� ' e---'�----"�`="-I-_----------- ------License # ��'�� Phone -- Installation will serve: Residence partment House°❑ Commercial:❑Trailer Court ;❑ Motel []Other ----------- Number of living units:-------- Number of droorn-s--�S�---__- _Garbage Grind �__--_ Lot Size - -� Water Supply: Public System and name "------"-"----•--•" pp Y= 'Cr`� �!�`- Private ❑ Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ - Hardpan ❑ Adobe-El Fill Material,4- A__ If yes, type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) ` NEW INSTALLATION: (No septic tank or seepage pit permitted ifublic sewer is p available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TAN — / V Capacity Ze---- --� ------------ �---- 1-quid Depth _'T��r._.----"--- Ca ' p -� TypeRe-001414wateriaJ'1 y No. Compartments -_ _______ Distance to nearest: Well ------------------------------------ � J Foundation - --------- Prop. Line x .:-------- LEACHING LINE No. of Lines = . ------- --------- "---- Length of each line__je 0iAJ_ -.--_ -- TotalLength .�_;ld- 'D' Box : _tea Type Filter Material ___.___'_______Depth Filter Material _-_ ----------------- ---•-------- Distance o nearest: Well .- _=_�-�-- -_--- Foundation JProperty Line _ " _-- - - - ----� I?tY_ __._ �-•-----------••--- Depth ej SEEPAGE PIT De p -- ___ Diameter � __ --- Number -- __ ___ Rock Filled Yes 'kr' No .0 Water Table Depth ------/. -/------------------------------Rock Size - --/�=-----__�?11/--------- -• Distance to nearest: Well ---------____-_" F .._Foundation p, Line_/ --__ Prop. �..S_/_ REPA IR ADDITION(Prev. Sanitation Permit# ---------------------- Septic.Tank (Specify Requirements) __________________.- -------------------------=------- isposai Field (Specify Requirements) _-________" -._ __ -------------- -------------------------------------------------------- ---------- ----------- --- - (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. dome owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --------------------- 4- - --------- ----- ------------•------------. Owner BY I ------ Cry. -moi (If other an r�srt3er) - --- Title ----- FO DEPAttTMENT U E ONLY APPLICATION ACCEPTED BY --. __._ . __ BUILDING PERMIT ISSUED "-------- -- -------------------------------------------- DATE ? ADDITIONAL COMMENTS - DATE --- ------------------------------ ----------------- ------------------------------------------------------------------------------------------- ------- --- - -- --------- -- ------------------------------------------------- Final inspection by: --- ------ ------------------------- ----------- Date------ 1 SAN JOAfUlN LOCAL HEALTH DISTRICT - � E. H. 9 1-'68 Rev. SM �I-- ' 7 '