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FOR OFFICE USE: APPLICATION IFOR14NITATION PERMIT ................................................... 3�7 C Permit No. ....! (Complete in Triplicate) ...........'.... This Permit Expires T Year From Date Issued Date Issued, -.,3....7/ *2—t (7 0 — ,3...7 .- 2r3— l7n — Application is hereby made to the San Joaquin local Health District for a permit to construct and install the work herein , described. This a plication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations.- JOB egulations: JOB ADDRESS/LOCATION P.rt.!►�Xi. -, ..: � �:. II f _ _ A ¢ 1�...� ..P.�..-CENSUS TRACT Owner's Name H.1.4.�-J '_/ .f' %'.r. ..................................................... R .Phone .�"3�:.�p a45".......... � ........ :........ .®, Pj Address . -....-..---•- .._QX.-. . -...- -•----...-..-•-_-•.••-•--•-----•---------------------------•..:...: City ---�4 ...K...-.........-••••-......... Contractor's Name At / ----p-/W-d.:rli ............. =aicense'# ..'.- ................. Phone ............................... Installation will serve: Residence Apartment House 0 Commercial 'OTraller Court 0 l Motel [j Other ................................... Number of living units------------- Number of bedrooms....j......Garbage Grinder -.- .--:- Lot.Size•.__4.,5'S- rr Water Supply: Public System and name ................. - .._.._._...................-...............................................Private Et}� Character of soil to_a depth of 3 feet:.�,.Sarid 1] SiltwE]�Clays Peat-0,Sandy_Loam_E]_m_Clay__loam 1 Hardpan E] Adobe ❑ Fill Material ............ If yes,type .............-.............. (Plot pion, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) : NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer Is available within 200 feet,) PACKAGE TREATMENT [ 3 SEPTIC TANK{ Size..._............................................ Liquid Depth __._.-__..._..........-:-- Capacity� Q.�.�_ '`Type - + _ aterial--_••----------------- No. Compartments .. . ..... Distance to nearest: Well ...............Foundation A .......... Prop. Line _ZIP.......:...... LEACHING LINENo. of Lines ( ] ........................ Length of each line.-. Total Length ........... 'D' Box / Type Filter Material ../' .:Depth Filter Material .. . "I- " Distance to nearest: Well .l ©---`f.:--- Foundation ..... Property Line ' I7 •---- SEEPAGE PIT �---��-- [ 1 Depth ..._..---_--------_ Diameter ................ Number ........._._°_::.__ Rock Filled Yes-0 . . No.(:] rk Water Table Depth ..............Rock Size Distance to nearest: Well Prop. Line REPAIR/ADDITION(Prey. Sanitation Permit# ............. ......_..._. } Date . ) Septic Tank (Specify Requirements) ..... l �j_V_ r. t D_;,posol_Field (Specify Requirements) ......'-._-...::.-�................. . 27 •..-• 5• �•............................ Nl/1V� k { • ...........................11.--• -.H.. �.= - W, (Draw existing and required addition on reverse side). p 1 hereby certify that I have prepared this application and that the'work will be done in accord anta with Son 4 to County Ordinances, State laws, and Rules and Regulations of the San'Joaquin Local Health District. home owner or licen. sed a signature certifies the following: "i cert th i performance of the work for which this permit Is Issued, I shall not employ any person in such manner as to bec a 'ect t Wo ns Compensation laws of California." Signed ............................ Owner By ..................................... . ti Title ....-..--.:...:. -.......-_.. (If other than owner) :....:.................. .. . FOR DEPA MENT USE ONLY APPLICATION ACCEPTED BY .. .. . ............ ••---•:.-._.....------. ........... DATE...` ..... .......�-- -- ......... BUILDING PERMIT ISSUED . --..........•-•--•------• ----- .----.--....DATE -...------•................................ ADDITIONAL COMMENTS ............................................:......... _.... - ..-...-.--..... .................................... ...................-................. •--•---------------------- ----------- --•••-••---• ..........•.................................................................--......-....... . Final Inspection by: ................. ..............................Date SAN JOAQUIN LOCALHrHEALTH y DISTRICT _ E. H.13 24 1-'68 Rev. 5M 7172 3 m