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OFF.Is-. fi�ee. `>y APr KATION Fdh S/(AIITATION.r MR �•p (Complete In Triplicate) 2 Permit No. _,7 - .......-•. ....... ........:� f This permit Expires 1 Year From DoteRaued Date Issued ...�I1 17./ 1 1 Application is hereby mode to the rSan Joaquin Local Health District for a permit to construct and install the work herein described• This application Is matte in compliance with County Ordinance No. 549 and existing Rules aril Regulations: JOB ADDRESS/LOCA 7 Owner's Name .. / TRACT -.----- �rr��7 ..................._.. . . .... . ... Phone..��. Address ...�rC..p�.lo.�. . �.�. ._ .........-.............. Y._Ss' Confractor's Name ....;. _ ... :......_Ltcense ip 7.,�a.. / � ---._... - Oc �c� Phone .. . Installation will serve: Residence❑Apartment House C❑ CommerNaraller Court ❑ _ .Motel ❑Other............................................ Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size ... ........ Water Supply, Public System and name ._.................... t __.._..... ....Prlvate)K 1. Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam fl Clay Loam D Hardpan ❑ Adobex Fill Material ..-.,...... If yes,type i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) V t NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK:[ I size..........................r. . Liquid Depth Capacity .................... Type ...--... ......... Material......- No. Compartments ..... ..................... Distance to nearest: Well ..............._...................Foundation ..._....... .. ...... Prop. Line......... ._.._. LEACHING LINE ( I No. of Lines .. Length of each line............................. Total Length 'D' Box ......---._. Type Filter Material ....................Depth Filter Material _...__.__._.». Distance to nearest: Well ........ Prop".._...._». Foundation ...................... propLhts ....................... SEEPAGE PIT [ ] Depth ............ ....... Diameter Number ........._....._.. .. Rock Filled Yes ❑ No Q Water Table Depth ..........................................Rock Size .............................. i Distance to nearest: Well _........._........................ .Foundation ........-.------.. Pr h -• op.;Line .........--..... -�. REPAIR/ADDITION(Prov. Sanitation Permit tR............................................ Date -.........................._.... ) Septic.Tank (Specify Requirements) .....................I-------- _ _ Dis Isla Feld (Specify R viredhents) .......... s _._..........* - ._.....__'V._ ............. ....exi ...... ..........__..._.adds I ------ ------ ---- -- r (Draw existing and required addition on reverse aide) 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. Home owner or licen- sed agents signature certifies the following: "I certify that in the perfor nce f t e work for ch this permit is issued, I shall not employ any person in such manner as to bee su 'ett to o ma 's -ompentatl In s of California." Signed /1..� _ -0444.00 U- -- ----- ____ Owner _... By,_...............(I .... Title ....._...................._. . o an own i AM FOR DEPARTMENT USE ONLY t �APPLtCATION ACCEPTED BY.... .._.. . .....\,.. . ....................... DATE..............._......' • BUILDING PER ISSUED ..._ .' �--..�_. ..._ ............ .............. -. ....._DATE........•___......_'_ ITIONAL COMMENTS.._-..-_... ................._..._...........__ -- ....__..___...... ....................................._..............-......_...-----------------...-_.-•___ ... ...................._....-`__..--------- - - . _.._..._spection............by; .... ... ......... ..........................-.._.......------ - Final Inspection by: ...... ...._. . _.................................-.....---.._.. ................ .oats .... .' ...............' }t....._... _.... -•-•---... SAN JOAQUIN LOCAL HEALTH DISTRICT ' _E. H. 9 1-'68 Rev. SM r r-L J