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FOR OFFICE USE, Arr^i'iICATION FOR S<.NIlAi10N i'il('•Ji 1111. 1111... 1111. �•....t No. (Complete in Triplicate) 1111. .......................... Date Issued .. .'��..� _.,.,_•„- This Permit Expires 1 Year From Dole Issued Appltcotion is hereby made to the Son 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, JOB ADDRESS/LOCATION ...... S.. ..... rCAC. .. CENSUS TRACT ...........5.......... Owner's Name`....(JJr.P�.N�C+;......� !1.�4IN.fa............... .....phone ..$35.....ya.�.�?..._ Address .....DL..*A.61a,........sISZ:.....K!A?`'...3.3...........7.............. ............City .T!,!.P. .......................................�....... Contractor's Nome �.(�. ..Qf�2�}..3.4... �...SQ!l..A.............................License i .2 5 .',113... Phone Installation will serve, Residence®Apartment Houset]Commercial ❑Trailer Court ❑ Motel ❑Other........................................... Number of living units,. _.._ gCrCE$ Number of bedrooms ........Garbage Grinder ............ Lot Size ..a$............................._r_ Water Supply: Public System and name .. ...................._......._......................._.................Private a— . Character of soil to a depth of 3 fees Sand 0 Silt❑ Clay (3---Peat❑ Sandy Loam ❑ Clay Loom ❑ Hardpan ❑ Adobe ❑ Fill Material ............If yes,type............................ (Plot plan, showing size of lot, location of system In relation to wells, buildings, eft must be placed on revere side.) NEW INSTALLATIONt (No septic tank or seepage pit permitted If public sewer is liable within 200 feet,) PACKAGE TREATMENT ( I SEPTIC TANK j J Size .................................. .......... Liquid Depth .......................». Capacity — . ..... Type ..... ............. Material................... . No. Compartments ....... Distance to nearest: Well ...11. ....11.......................Foundation .........11.1.1..... Prop. Line...«1111..«..«.�.� LEACHING LINE [ J No. of Lines . ......... .L ngth of each line _............... ......... Total Length ............ _»...._.6 'D' Box ...... . . Type Filter M vial ....................Depth FII Material ...._...-................... »....»»...� Distance to nearest, Well ....... ............... Foundation .... ..... ............ Property Line ........................ SEEPAGE PIT ( J Depth . ...... . Diomater ...........»... Number .............. ............ Rock Filled Yes ❑ No QtA Water Table Depth ................ .............».............Rock Size - ............................. Distance to nearest: Well1111.. ................ ..............Foundat ......11..11... Prop. Una ................._.� REPAIR/ADDITION(Prov. Sanitation Permit# .............. .......................... DaN ......... ..........«..«1111.) Septic Tank (Specify Requirements) _ _.....................................i........«....«...._....«...._.._................................«..............� t Disposal Field (Specify Requirements) .....ItEAC1�-..«�.AL•I.G........................................_......»................................. ........................................................_. _ ............................................................«........................................................... .W ......................................................................................................_........................................................................................... (Draw existing and requlred addition on roverso side) I hereby certify that i have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, Slate Laws, and Rules and Regulations of the Sen Joaquin Leda Health District. Home Owner K lid"- sed agents signature certifies the following: "I certify that In the performance of the work for which this permit is Issued, 1 droll nst employ any person In such manner as to me subject to Workman's Compensation lawn of California.” S,gne,d �. - �• �!'`1.. .••. . . Owner .. 1111 . .............................. ........................._. Jule of ....... 1I 1111 r'V... . A.I��4.. ...................... 1111.. ...................... gy than_o Ilfher than ownorl FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . .`SIR•.EJ•... .................................................................... DATE .....7 ........... BUILDINGPERMIT ISSUED ... . .. .... . . .. 1 1_....... ............ ...................................«............DATE ..............._.....................«. i ADDITIONAL COMMENTS 1111... .......»... ....... ..«.»...«_1111«.............« J ...:.::1111.. ::::::.::.»'....... .. / . .. ................... 1111. }y ............ ��— ... Final InsPeOL_ .,rrrFL' i�� . . 1. . ...............Date ...../1..:......... I 1111. . .r. SAN JOAQUIN LOCAL HEALTH DISTRICT i 13 24 7/72 3 M E. H. i-'68 Rev. SM I