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FOR OFFICE USE: {1 APPLICAT.IO', ... i2`NITATIONARMIT1. �J / --------.-._....._....... --•------- ... ''� (G Permit No. L4� - - - (Complete in Triplicate) ...................... ........ ........ ... I Dote Issued �.- This Permittxpires 1 Year From Date Issued ................ P, v Application is hereby madelto the San Joaquin Local Health District for a permit to construct and install the work herein descrioed, This�.bpplication i made-in compliance with County Ordinance No. 549 and existing Rules and Regulations: ti JOB ADDRESS/LOCATI N . -..:� Ns°1C:_N { ACT " -..---- { Owner's Name �� P � '...... li r2 �/ one Address �?_,.. -----------X,3..................... °:__ City Coritmctor's Name ........ -------------------------------- ----.License # ......................... Phone --_-------............_.._ `— _ `` 4 Installation will serve: I Residence ❑ Apartment House❑ Commercial; Trailer Court E]Z-4101;1_ /a `�"� � � Motel ❑Other ...... ....... . Co. V I - Number of living units.-. Number Number of be rooms ._.._.-.--__Garbage Grinder _._. - Lot Size -_............. ._____.•_._-..• ��,� ---Private ❑ ` Water Supply: Public System and name .- --- --/4�CldX. •----------------------------••-- <,<y Character of soil to a depth'lof 3 feet: Sand'❑ Silt❑ Clay ❑ Peat f Sandy Loam ❑ Clay Loam Hardpan [❑ Adobe ❑ Fill Material ........--.- if yes, type -----------_------------- r (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I t[ I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ! PACKAGE TREATMENT [ ] SEPTIC TANK![ ] Size------------------------- -------------- - ---- Liquid Depfh ...-_.------_--------------e� Capacity - Type ----- ------ Material...................... No. Compartments ............... Distance to nearest: Well .........._........................Foundation -------- ------------- Prop. Line ...................... LEACHING EINE ( ] No of Lines Length of each line.........._---------------- Total Length .........---_-- f 'D'I)Box .--- Type Filter Material --------------- ----Depth Filter Material --------------------------------------••--•-; Distance to nearest: Well ......................._ Foundation Property Line -- --------------- Rock Filled Yes [71 No 01 ,SEEPAGE:PIT [ ] ' Depth -------------------- Diameter --------------._ Number -------- ..... - Water Table Depth ------ ---••------ ..........Rock Size ._------ ---------------------- t II tance to nearest: Well '`._--_--___----.. - --------------------- ...FoundationProp. Line ...................... Distance REPAIR/ADDITION(Prev. Sanitation Permit -------- Dat } i Septic Tank {Specify Requirements) // Disposal Field (Specify CRequiremen s d__ _ /!�� 1� �`� +-? .. .................. ------------------ - --------- •------------------ -•---- -------------- .............................. (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 Regulations of the San Joaquin Local Health District. Nome 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.Workman's Compensation laws of California." Sig d ..............._.....-.._..�_I.._.... Owner.- j {-------- r By fo_�,_r__t' ' --------- ---- Title ....... .. . .. . -- .------ .... . han owner} FOR DEPARTMENT USE ONLY _. i ACCEPTED 6Y .------ -- < ..tv DATE ..-sz ..:� s}'- ---------------- APPLICATION BUILDING PERMIT ISSUED; DATE ADUIT NA_L C M >iS�'.�f .7f. - -- � ;,ej�- -.c•I �c,--P-DATE . _ .. M ��. , - .. --C Final Inspection b Date ..... ...... .. ..-r. _ i SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.