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FOR OFFICE USE: APPLICAT.IOi :-.3RD NI-TATIONARMIT --------------- i 1. Permit No. L�1- ------ (Complete in Triplicate) Date Issued _Pq__- ' , �I. This Permitltxpires 1 Year From Date Issued7 --------------------------------------- .._ .. ._ .___. `Application is hereby made lto the San Joaquin Local Health District for a permit to construct and install the work herein described. Thisapplication i made, in compliance with County Ordinance No. 549 and existing Rules and Regulations: ----- JOB ADDRESS/LOC N -�. r�N ! - ��' � '� jIW,,f,464 ACT " ------ � _�- - -------------------------------------------- C Owner's Name ------ - ---- � _ hone --------•--------- - i Address ---------------------------------- .-,, -- -- ---- _ - -------------`- ,,;,' Contractor's Name -- cPhone �P� -- --- ------------ License # ---- ------------ ?. y J C Installation will serve: Residence ❑ Apartment House❑ Commercial XTrailer Court ,❑�+�t.dw�^ � ►fir V�! i Motel ❑ Other '... v Number of living units:-.-_X11 Number of be rooms ___________Garbage Grinder ------------ Lot Size ----------- --------------------A z& ---- Water Supply: Public SystemIand name_ ----- - _ --------•---- Private E] Character of soil to a depth'!)f 3 feet: Sand'[] Silt C1Clay El Peat Sandy Loam -El Clay Loam E] Hardpan ❑ Adobe'❑ 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.) !C4 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) d PACKAGE TREATMENT f ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depfh .-----------•------------- __________________ Material____.__-_----------- No. Compartments CapacrtY -------------•--_Type p --------_----- Distance -------------Distance to nearest: Well ----------------------------•------•Foundation -------- ------------- Prop. Line ---•---------------- I` LEACHING,LINE [ ] NO. of Lines ------------------ - --- Length of each line---------------------------- Total Length ----------- ------------ ----------------------•- ' 'D'I�Box ------------ Type Filter Material ________--__-_-- --Depth Filter Material Pro er Line -------------------•-.--: _ .,Y Distance to nearest: Well ----------------_------- Foundation ------------------------ Rock Filled Yes ❑ No i❑ ,SEEPAGE-PIT [ ] , Depth -------------------- Diameter ---------------- Number ------------------ I Walter Table Depth ------ --- ----------Rock Size ------------------ { -Foundation -------------------- Pro Line -------- •----- f S t Distance to nearest: Well __ " - -----------------• � � REPAIR/ADDITION(Prev. Sanitation Permit _------- ----- ---------------------------- Dat ---------------.------) Septic Tank (Specify Requirements) ___ ___f. __ ` '�' `"�`" 69 _ 1 -- -- ----------- - ------- ' f Disposal Field (Specify .Requiremen ![ C _ �' !I° u ' ---- --- ------ --------------------------------------------------------------------------------------------------------------------- {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 Reguliations 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, I shall not employ any person in such manner as to become subject-to.Werkman's Compensation laws of California." Owner- BY Title --- - - - -- - - --- - - ----------------------- ------------ - -- - ----------------------- - {!f oher tharil owner} II FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- Buz : --------------------------- DATE _ - 1--------------- BUILDING PERMIT ISSUED;I _ M -- �' - - �-- ------------ --- � : ADDIT NAL C t . 64 ` - -- - - - - ---- --------------------- - --------- ------------ �. �Date --Final Inspection SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M