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FOR OFFICE USE- APPMATION RM 5AN11TATION PERMIT IC*mplef* In Triplicate; Dab kww ....... ...... ThisPermitExpires 1 Yew From 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. 549 and existing Rules and Regulations: r:), 5 0 k, JOB ADDRESS/LOCATION — ------ .............CENSUS TRACT ............... . ..... ... Owner's Name .........................• ...........................Phone ...... . .... . ........ . .. . ..... Address . ....... 5-3c ir__ ...... City --- ............».,........_............. ........... Contractor's Name ... .License. Phone —, . . . ..................... Installation will serve.. Residence,Apartment House f3 Commercial OTrailer Court C] Motel [] Other ...... .......... Number of living units: ... Number of bedrooms Grinder Lot Size ......... Water Supply: Public System and name .... .... ___ ......... ................ — ............ _ .. . .... .......... —..........-_-._Private — -------- Private C] Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay Peat [] Sandy Loom Clay Loom rl Hardpan AclobeC] Fill Material 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. lNo septic tank or seepage pit permitted If public sewer is available within 200 fast,) PACKAGE TREATMENT SEPTIC TANK T Size..._..............,,.„.. ...... ...... ... Liquid Depth Capacity ........ -------- � TypeNa Compartments Material..........._.._ ........ N Distance to nearest: Well ................... . ...... . ...... Foundation ....... . .... . _. Prop. Line LEACHING LINE j j No. of Lines ........ Length of each line.—_ .............. ___ Total LerVj+ .... 'D' Box Type Filter Material ...._......_.-._....Depth Filter Material ... __ ...... ....... Distance to nearest, Well Foundation Prop” Line SEEPAGE PIT i j Depth ...... ... Diameter Number ........................... Rock Filled Yes 0 No 0 Water Table Depth ..... ......,»........... .............Rock Size »........_......._ Distance to nearest-, Well litav* Lim ___ . ............ REPAIR/ADDITION(Prev, Sanitation Permit #_, . . . .. ..... . ...... . ............ Date ................»..---_ ........ Septic Tank (Specify Requirements)............... ...._........_..,.....-................ ...... . ......... . ..... ------ * ...... Disposal Field (Specify ReAuirements) ...... . . ..... .......... ............ ...................._....-...-._..-........k......._-._....-......_. (Draw existing and required addition on reverse side) I hereby codify 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 ft"ullotions of the Son J*"Uin Local Health District. Home owner of licen- sed agents signature codifies the following: "I certify that in the porformonce, of the work for which this Permit it Issued, I shall not employ any V*** 10 such 4*01111W as to become subject to Workman'% Compensation laws of California." Signed ......... Owner By___ ........ 'Title .................................. (If other than owned USE Way APPLICATION ACCEPTED BY,_-- ...... __.............. _... DATE F -f! / BUILDING PERMIT ISSUED .. ........ ...... ___ ...... ................... .. .. . .. . ........... ........ ... DATE ................ ADDITIONAL COMMENTS ....... ....... . ... . ..... . ............ .......... ... . ... ........ . ..... __ ....... ..................... . ....... . .... . .................. . ........ . ................ ............................... . ...... ....................... ........ ................... ...... ...... ...... ...... ............... --------------------------- ----------------------------..- IL . On ... ....................................», ........... y: .... Final In SAN JOAQUIN LOCAL HEALTH DISTRICT E, H. 9 1-'b8 Rev. SM