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FO's OFFICE USE: APPLICATION FOR SAkiAkIiON PERMIT Complete in Triplicate) Permit No, 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 and install the work herein described. This application is made in compliance with County Ordinance No. 549jand existing Rules and Regulations: JOB ADDRESS/LOCATION{.---------/_ e of CENSUS TRACT `----------------------- OwnerOwner'ss Name ------ ---- l------ Phone Address --------------- '`5 City x--------------------------------------- Contractor's Name ----. E"---------------------------------------------------- --------License # ---------:-------------- Phone -- ------------------------•-- Installation will serve: Residence Afl Apartment House Commercial [-]Trailer Court ! Motel Other -------------------------------------------- Number of living units:-- ----- Number of bedrooms __-----Garbage Grinder ------------ Lot Size ` ' -.'___________________....... Water Supply: Public System and name --------------------------------•----------------------------------------------------------------• ------------Private,rj Character of soil to a depth of 3 feet: Sand-'E] . Silt E] :. Clay Peat, Sandy,Loam. Clay Loam Hardpan El IalAdobeillMIfyes, type ---------------------------- Plot plan, showing size of lot, location of system in r ti wells, buildings, etc. must be placed on reverse sides) NEW INSTALLATION: (No septic tank or seepage pit tied if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK Size-Liquid Depth - -------•---•-•------- Capacity .!_ ----- T p ----------- __7C'aferial--- 'r_'_ No. Compartments Distance to nearest: rqe________________________Foundation _.l q_----------- prop. Line __. ,-----------a LEACHING LINE No, of Lines ___Il _________ Length of each line----_ Total Length ,. _'______________ p Depth Filter Material _____'__'.------------------------D' Box --'----___.-- a Filter Material -__1__'__-- D' nce to ea est: Well ____ q"____ Foundation ----Property Line __0------------------- Rock Filled Yes,0 NoSEEPAGEPITehDiameter :__________ Number ____'.__.._____.____._ 0 ater To I epth -------------------------------------Rock Size istance o nearest: Well ------Foundation Prop. Line -7+-_________-_-__ REPAIR/ADDITION(Prev. anitati n Permit# -------- ----------------------------------- Date _____----_-__-__-_-______.__-__.__) E SepticTank (Specify Re uire nts) ------------------- ---------------------------------------------------------------------------------------- -•-----------------•-------- DisposalField {Specify e irements) --------------•-,-------------------------------------------------------------------------------------- ---------------------------- 1 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. Home owner or licen- sed agents signature certifies the following: I certify that in the perform nce of the work for which this permit is issued, I shall not employ any person in such manner as to"become subject to Wo m 's Con0ensation laws of California." Signed "Owner By -Title --- ------------------ r If other than owner) FOR .DEPARTMENT USE ONLY p APPLICATION ACCEPTED BY ---1_2 DATE ff BUILDING PERMIT ISSUED --------------------- DATE ------ ADDITIONAL COMMENTS 5 r ' - :7_ _--------_-------- ------------------------------ p ction by: . J.a r. -------------------------------- DateFinalInse 3 SAN JOAQUIN LOCAL .HEALTH DISTRICT Cj`/ d/1 I E. H. 9 1-'68 Rev. 5M