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} FOR OFFICE USE, APPLICATIONFO1t S A N PERMIT 7. FF1l Permit No. �� (Cory Permit In p a ) _. Daft Issued This Permit Expires i year Frere Daft Isswed Application is hereby made to the San Joaquin local Health District for a permit to construct and Instal) the work 111411 + described. This opplicotion is made in compliance with County Ordinance No. 514 and existing Rules and R"ulotlona { _ • Y JOB ADDRESS/LOCATION . S7l�O w'N'�A.y.. J•Z ....CENSUS... ........ . _ Owner's Nome V�t KJ �Ac�S aA)................................................. .................... .................»... ' Address S,71w W• '14 c l /..2— . ....................City Lod► .. . ........ Lo��...3 j Contractor's Name G 4_1 •�` license i/�7 �+� Installation will serve: Residence pErCpartment HousoZ rclol❑Troller Court 0 Motel ❑Other.................................... Number of living units: Number of bedroornsv° .Garbage &I . ........................................ Water Supply: Public System and name ........ . . ......... Pr ~ Character of soil too depth of 3 feet: Sand❑ Silt❑ Clay Peat❑ loom 01 Gay Loan^❑ Hardpan Q Adobe Q Fil • ial ....... ...if yes,type... .......... ............ (Plot plan, showing size of lot, location of system in relation wells, build( s, etc. mvwplaced on revers» elde.l NEW INSTALLATION: (leo septic tank or seepage pit perm il public sews is available wi M 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK i I Size" -•• .....•....••....... •-• • Ospth ••_••"'"-'"..... • Capacity .._ _.. ... .I,rlTlfpp_.. at�iol...................... No. CompartrnMh ............. Distoncr- to neorest: Wel) ..... ....... 4 .... ....I.....Foundation ...................... Prop. line LEACHING LINE [ ] No. of Lines _..- ..... Length of ine..................... ...... Total .. ..............»..... : . Type Filter Material � . ..........Depth Filter Material ...... Distance nce to nearest: Well ...................... nclation .. llrte ............• .. ` SEEPAGE PIT [ i Dapth __ Diameter umber ....... Rock led Y ❑ NO Q Water Table Depth }....Rock S .......................... ... Distance to naarest: Well ..........Found on .................... l »....._.... : REPAIR/ADDITION(Prey. Sanitation Permit# .................................... -•••--•v? •- ..�.... _... ... .......»...»_».. y Septic Tank (Specify Requirements) .............. ........................ _... . ..I� -.....�..•....-. Disposal Field (Specify Requirements) ..fO..... Le Aok...L',o.. .......l.ra.� I ..l,.,0A) ,1 ................. .... ............................ . _............._......................................................................... ............ .... (Draw existing and required addition on reverse side) "W 1� ,,�.� i hereby certify that 1 have prepared this application and that Ow work wbe done kn CisPR iRw ill County Ordinances, State Lows, and Rules and R-gulations of the Son Joaquin local tteaNlr Dktrkt.Henn owner K Neest- sed ogents signature certifies the following: "I certify that in the performance of the work for whici his permit Is Issued, 1 shell net employ any penes In sw`nu mer as to become subject to Workman's Cump•ensation lows of California." Signed _ ._. ... . ..... ....................................... Owner /+ � ... -•..................... Title . Da'�c` -Cfl �c.. ef�/nLf��- By If at than owner) O E ARTMENT USE ONLY _ �.._ t_.,,�..�US— APPLICATION _ APPLICATION ACCEPTED BY . DATET`7 ••• •• �... .. ........ ..... .................................. ............... BUILDINGPERMIT ISSUED . .. .... ................................... ............... .............DATE .... ................................. ADDITIONALCOMMENTS . . .. . . .................................................. . .......................... ..... L .. .. ...... ............................. . _. _... . .........»....... . .. ........... ...... .... .......... .. ....... ... .............. . .......... ....... ...... ........... �7_7r........... Final Inspection by: Date ........... -...... . ER 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 6/711 3H