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FOR 6�1`IeF`USE- APPLICATION FOR SAMTATION PERA.,AIT— A ..-1 Permit No- ------- ..... .......... . � 114. 1 i�- �-- P-�W' F (Complete in Triplicate) ...... ...... bate Issued .........<.__,._ .......... This Permit Expires 1 Year Frain Date Issued Application is hereby made to the ioln Joaquin Local Health District for a permit to construct and install the work-hertih .described. This application is/made-in compliance with County Ordinance No, 5A9 and existing Rules and Regulations. JOB AD R[.'P.0.)S�..CENSLJS TRACT ... ----- _ DRESS/LOCAtION ------------ Owner's Name Address ...... ........ ........ .......... ..City _Aicense # /Xs(77� Phone Contractor's Name Installation will serve: Residence 7 Apartment House 0 Commercial' Trailer Court 0 F_ F,)(-?ANS I 0/�'/ Motel ©Other Number of living.units.r-=. .. Number of bedroamv—_------,Oqbc�ge Grinder-==... Lot Size ......... ~' Water Supply: PublicSystem and name .................. ....... .......------- ----- Sifter" Clay [] peat[3 Sandy Loom IV Clay Loom Character Of'Soil to a depth of 3 feet: SorraR-A Hardpan M Aclb6eQ Fill Material Na- 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 if public sewer is available within 200 feet,) Liquid Depth ...... PACKAGE TREATMENT I I SEPTIC TANK Capacity J�!?A.,__ Type AC,C#JMaterial... Na. Compartments ............ J dation ...AO f Distance to nearest,. Well -,_,-..Four --_ Prop. Llne/R.Ai--- ........ Total Length .......... No. of Lines ........ LEACHING LINE & Length of each line._ 'D' Box Type Filter Materia *---Depth Filter Material Distance 4o nearest: Well ..... Foundation Property Line SEEPAGE PIT Depth _J --- Diameter _.------------- Numbe, -------------., Rock Filled Yes C] No C3 VVoter Table Depth _--_............ ........,--Rock Size-----_------------------- i ____... Pro Distance to nearest: Well ... ------__------------------------Foundation ....... p. Line =.......--•-_•---_--- I .................... Date ............. REPAIP./ADDITION(?rev. Sanitation permit# ................------- Septic Tank (Specify Requirer4ts) ...... ....... ...................... ............. Disposal Field {Specify Requirements) .7-1 . ....14 ------------------ ------------------------- -- --------------- .......................... ........ .................. (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 Son Joaquin County ordinances, State Laws, and Rules and Regulations Of the Son Joaquin Local Health District. Home owner or HcOn- sed agents signature certifies the following: arson in such manner a "I certify that in the performance of the work for which this permit is issued, I sball no#mplq. vy. p as to become subject to Workman's Compensation laws Of California-" 4�... Signed ...... .1y...................... ......... Owner r ----------------- ----- BY ............Ao;'eR, * ................. Title .............. (if e t an ow r, o FOR dtPARTMENT USE ONLY DATE --- APPLICATION ACCEPTED BY ....----t.• ......._.............- BUILDING PERMIT ISSUED -__- --..............•.__..,..-,.........._-.-........___--._............... ..._..._...._.DATE ........ ADDITIONALCOMMENTS..............................................................•--................. __...................... ........................................................................................... .................__ ................ ............... ............I............ ..........................I............ .................... ......................_............. ................. ...........__----_--------------_------ ......... ..... .Date - -------- Ino] Inspection by........ _. SAN JOAQUIN LOCAL HEALTH DISVUC.T U 0 1-'AR Rev. 5M