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FOR OFFICE USE: +- ............................:..........................: .�APPLICATION hOR�•a�TViT�1TION Paw Permit (Complete In Triplicate) ........................................ This Permit Expires 1 Year From Date Issued ............... Hate Issued .-Z.............. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This appiicati Is mod�I co 11 11 c�vit Co nt , r onan 5A and existing RvIes and Regulations: JOB ADDRESS/LOCATION`S�®��y''9 GCCs�t'' � CE1V5195 ekA Y .-.# �--1-_--- -:.. Owner's Name L _�..-----/ 1._ �. ..1 .. ..................................: ............... ....P one ..-•--•.•- ..=_ ...C it h `]�yis�s/ -� Address .......................................I............City "�1 � ��..... ...........--. ---- .--..-.---- l Contractor's Name ......... .... .......1�...��---------•-...............-........................License Phone Installation installation will serve: Residence®Apartment House 0 Commercial❑Troller Court ❑ Motel ❑Other.....--------------------•................... Number of living units:............ Number of bedrooms Garbage Grinder ............ Lot -••-------- Water Supply: Public System and name --......................................................_..-----........._ ..................................private ❑ i Character of soil to a depth of 3 feet: Sand l!� Silt Q Clay ❑ Peat[], Sandy Loam o Clay Loam❑ Hardpan❑ Adobe 0 Fill Material ............ If yes,type .............. ...........'` ........:... j lPlot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be plocf tl on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet l PACKAGE TREATMENT [ ] SEPTIC TANK I } Size....../,2.4 r�i..................••--..--. Liquid Depth .......................... Capacity ADO------ Typec�G........ M vial.---••- ---•-........ No. Compartments ......_-- Distance.to nearest: Well/4-Ag f- -- ---------------F ndation ..._ ---- __ Prop. Une .___ ...'t...--.-. LEACHING LINE j No. of Lines ........................ Lengt of each 'll ---......................... Total Length ....._...._................. . Y 'D' Box ------------ Type Filter Mate al ............. .....Depth Filter Material ............................,............. ..0 Distance to nearest: Well ....... ............... F ndation ........................ Property Line .........................-A SEEPAGE PIT ( l Depth .................... Diamet ............... Number ............................... Rock Filled Yes ❑ No ❑ Water Table Depth ••-•-----• •-------------•-- .................Rock Size ---•--_--.........._ Distance to nearest: Well ----------------- .. -•--.....Foundation .................... Prop. Line ...................... S REPAIR/ADDITION(Prev. Sanitation Permit# ..................... --• .................. Date --------------------------------A Septic Tank #Specify Requirements} .......---......�--..... ........ - ........ ••-• ...... ............ Disposal Field (Spe ' y siequ' ementsl ------ ��._... ' ------------------------------- .... ------------ ---.-•---.---._.......---•--------...__ ......_..----------....-- ...................................... . (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 wHh Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,,District. Home 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." F Signed : - ................................... Owner Al BY ..................... xitle ---------- ------- ........... • --•---..•-----• -----•-- •--------- . o#her tha wnerl FO DEPA TMENT USE ONLY APPLICATION ACCEPTED BY ----- ------ •- •------------------ DATE __... . BUILDINGPERMIT ISSUED -------------------------.........................................----------- ----------- ...... •------DATE ...................... ......... ADDITIONALCOMMENTS ------------------------- _----•---------------- ................-.. _-------_---- --------- ---------- -•---- ............:........................... ..................---•------ -------------- ----•------------ ....... _.._.. ----- ..... ........................................................__._....-------- ...---... --- .. . . _._.... .. f ................ ... . / Final Inspection b _ - ---- -• -• - - - •--•..............•-...------••-------•-----•--•-...._Date _:� - - -��- -7 -•----...._.._ EH 13 2h 1--68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT y 8/7h 3M