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� - 1 /'�11 •1�./'111V1\ 1 VI♦ JMI\tIM11V1\ 1 VI\/ 111 � - �� (Complete in Triplicate) Permit No. .... This Permit Expires 1 Year From Date Issued Date Issued /5p:..�- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descri a Tis application is made in.compliance with County Ordinance No. 549 and existing Rules an egu ations: JO RESS L � 4u�� �,�WAJI // 4 � �/dN y --- S . . __ CENSUS TRACT Owner's Name ---- -•----------------• �E - ----- -Phone lc,- ` Address _. ............................. ` ........... city Contractor's Name .. ,--- -License# O........ Phone Installation will serve: Residence ❑Apartment House erci¢l ❑Trailer Court C]50 Motel ❑Other _.......... -FC .1.:.___.___._ - Number of living units:_.. _... . Number of bedrooms ...........-Garbage Grinder' . Lot Size - ..................... ................ Water Supply: Public System and name - ----------------------------------------- ----------- - -------------------------------------------------Private fVr Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam( Hardpan ❑ Adobe FIFill Materil .. _ _._. If yes,type ................. .... --- (Plot _(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) r NEW INSTALLATION: (No septic tank or seepage pit permitted\if.pVblic sewbr is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK Si e__..-.. [ l � �,t'�...-.n -.( Liquid Depth wS...T------------- Capacity - Type � Material�..� �� ' . No. Compartments Distance to nearest: Well I.CV.._.1---------------Foundation /.Q_._.._... Prop. Line _.. ............... LEACHING LINE No. of Lines _. -. ._. Length of each line /f1Q Total Length .....: ........__ ' 'D' Box ___✓Type Filter Material .. .....Depth Filter Material . 14----------------------------------- Distance to nearest: Well AT 74....... Foundation Property Line . ._.f! ............. i SEEPAGE PIT [ ] Depth - _ _._. Diameter _----------- Number Rock-Filled Yes ❑ No ❑ k Water Table Depth- -------- --- --------..........................Rock Size _-- -------.--_.-- Distance to-nearest: Well . . . .. .... ....------------------Foundation . ......... Prop. Line ..._...- REPAIR/ADDITION(Prev. Sanitation Permit# ------- _ _.__ Date ..........__..I Septic Tank (Specify Requirements) - _ __ ._ _.. _ _ _ -------- _...-. Disposal 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. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .. Owner By i/j�/�+.... _r _ Title (If of r than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE _42 - 1 ._'G 7............... BUILDING PERMIT ISSUED _ _.. .. _. - - _----------------------- DATE _ ............... ADDITIONAL COMMENTS _ . ....... ........ - ------------------ - --- ............. -- ---..... ... ......... ..... - -- . ........ .. - _.... ... . ...................... -- -- ---- ------------------ ------------------ ------------- -- ----------- --- - --- .................... .......... ------. --._.. - -----• ---•-_..._ ---- --------------- Final Inspection by: ...-_------- _ ._....._._.--..__. Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M