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ISR OFFICE USEr APPLICATION FOR ANiTATION PRRMIT ' (�/�/j�pr.,Jj (Complete in Triplicate) Permit No. .--7�......../- ........... (�p� ..........il.. r., Y , Date Issued ..T '.7 This Permit Expires 1 Year From Date Issued - Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heroin described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/i.�AT(ON . .2 .. � ''Z .......1..7r:_. s` ... 6.. .CENSUS TRACT Ownor's'Nome ............................. Q- N!_-- yp�iy........... ._.__....._... ........._•._`........_._.........Phone ;�f�B. .�?�..�.. Address ..................... � :.... n r... ..........City .....h1.171 ,:........................----.-......_.................. Contractor's Name ......b,a. . G�ti$.(�.t�;�E.---..�y�,�1.. ._ Licenso 0 c ,rt�l�- Phone :��.'�I A. Installation will serve: Residence Apartment House fl Commercial❑Tratlor Court 0 Motel❑Other Number of living units:_...f..... Number of bedrooms ..-a...._Garbago Grinder ............ Lot Size .....JJ1.4; %Q ............ Water Supply: Public System and name ._......_. ......_._.1_.._.... ....' ........ ._.... ...Private Character of sail to a depth of 3 foot: Sand JZ Slit❑ Clay ❑ Peat❑ Sand Loam Clay Loam ❑ Hardpan❑ Adobe ❑ Fill Material ............If yes,type............................ (Plot plan, showing size of lot, location of system in relatlon to wells, buildings, etc. must be placed on reverse silo.) W NEW INSTALLATION: (No septic tank or seepage pit permitted If 1pyblic sower is available within 200 feotj /' h PACKAGE TREATMENT ( ] SEPTIC TANK Size_.'�' � .�K..-�.�"t_'l�r Liquid Depth , .. .! ^�+ Capacity .rte•-----.- Type l ic— AAateriai. � No. Compartments .... .... Distance to nearest: Well ....JG?r. . ...............Foundation ... 10........... Prop. lino .. .�! ....... LEACHING LINE 60 No. of Lines ------..7._.......... aa ... Length of ouch llne...._. da.--------_- Total Length .r .�C'.......... 'D' Bax ...1...... Typo Filter Material . ....Depth Fitter Material ----ffi...............................� Distance to rest: Weil .__:f Sl s�... .. Foundati �¢......... Property line .,r4'!`........... SEEPAGE `` [n Depth -- .Jj........_ �Yr- -- Numb*r ..3...........!_.....�... (toots Filled Yes (� lido 0 • Water Tube Depth _....--'-, ..........................Rock Size .....--rZe................ Distance to nearest-..Well ..,__.A�.........................Foundation ~ __...._ Prop. Lino ..,tel. �...._.. IISPAIR/ADDITION(Prov.Sanitation Permit a ........-.................................. Data ---_------------.-----_--,-.-) SepticTank (Specify Requirements) ........---•.....................................•..............................._.........-............_............._................. DisposalField (Specify Requirements) ..........................................................................................................................- ---... •............................•--........._..----•••.-•-- --•-•-_.................... ---------------- ...............................................-.........-----...--•-•-.................... ! (Draw existing and required addition an revorso side) 1 hereby certify that I has o prepared this application and that the r✓ork rAll iso den* In accorticnco with San Jes*uln County Ordinances, State Lora, and Buten and 11"utationt of the 'Sara Joa:aieln Local 14=12h District.Horno orjnc7 cr It=0- aed a8onta cignature certifies the followng: "I cortify that in the performance of the work'for which this permit is iaaaexi, 1 shall nc4 c=ploq any fossa In ouch roaam=1 as to become zubloct to Wortan Compeneation to rm of Col(fandas." Signed Owrw By ........... .. .. ... _........................ -......-.. --Ti _._............ .................................... (if other than owner) (FOR DEPA11TMENT USB ONLY APPLICATION ACCEPTED BY.......... ..........................................----......_............................. C- r. DATE..... .... BUILDING PERMIT ISSUED �. .di._ADDITIONAL COMMENTS ..�.�_-'... _...4... ._.... ...................................... ...... �i ...,� ar. .c .. .. .....................•----•... FinalInspection by: ............._..- ----------......._.... _......................................................... _.__Date....W X 7._ SAN JOAQUIN LOCAL HEALTH DISTRICT t E.H.13 241-•68 Rev. SM 7/72 3,6__`