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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............ ....•----•.._..-----.-..__._............ Permit No. ...�:r.176 (Complete lin Triplicate) 74 ..........----------.................:.................... This Permit Expires 1 Year From Date Issued Date Issued ... .-........:. Application is hereby made to the San 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. 544 and existing Rules and Regulotions: JOB ADDRESS/LOCATION ._... .y .!�.._..._.G°p -----_ *. ............... ..................CENSUS TRACT .......................... Owner's Name ' ..._. �.�- ._......�� ....--••---•................................•.....................Phone. Address ........ ../ ............................... City / �✓ �G ......................................... Contractor's Name ............ .............................----------....................:.._- ....--License #Q.25757.-a,_;_ Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court Motel ❑ Other ------ Number of living units.. Number of bedrooms ............Garbage Grinder ............ Lot Size ................. ..................... Water Supply: Public System and name ................................................ . ........--•---------- ---------------------------Private ❑ Character of soil to a depth of 3 feet: Sand r] Silt❑ Clay ❑ Peat❑ Sandy Loom Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material _.. ........ If yes, type ............................ (Piot plan, showing size of lot, location of system in" relation'to-Wel Is 6tiildings, 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 [ ] SEPTIC TANK-[ ] }�'; n Size.................. ....................... _. Liquid Depth .................I........ Capacity .- --- -... TypeL_,_ .......... Material........I....... ..... No. Compartments ...................... .V Distance to nearest: Well . ... .............. ..Foundation ...................... Prop. Line ...................... S LEACHING LINE [ ] No. of Lines ._ ----- Length of each line .........-----------....... Total Length 'D' Box --- Type Filter Material ....................Depth Filter Material :.._ .. ......... �1 Distance to nearest: Well ......................... Foundation .....:................ Property Line � SEEPAGE PIT [ ) Depth ...... Diameter ---------------- Number Rock Filled Yes ❑ No +❑ ' Water Tabie Depth ........... -----------Rock Size ............. .................. o Distance to nearest: Wei ...Foundation .................... Prop. Line ............:. REPAIR/ADDITION(Prev. Sanitation Permit ...... Date __________________________________I Septic Tank (Specify Requirements) .... .... �_. _ -L '��/✓/ _ Disposal Field_ i(Specify Requirements} A. h�____ .N4_...__.__ __�.l�(✓LQ ........, a..-. o...........I............. .r �- . n ........... ..................-..----- .. _ .- ;.. (Draw existing•:and required addition on reverse side) I hereby certify that I have prepared.fhis application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Gles rand Regulations of the San Joaquin local Health District. Home owner or licen- sed agents signature tertifies the following:,) "I certify that in thle,perf�orinance-of;the work for which this permit is issued, I shall not employ any person in such manner ,_,,.- as to become sublet rkman's Compensation laws of California.'' ) Signed = G/t --.-.--- Owner By .... .. . .......... "... ....._._.._.... ............ ... Title (If other than owner) 1 i- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. ---------- -------------------- - - -------- DATE .. -I. L.-.`1 .......... BUILDING PERMIT ISSUED ... ..... ...................---------------..._..............._................... ..- ....DATE ...... .......... ............... ADDITIONAL COMMENTS ................. ..... ..................... - �._...._.. .. . .. ..... ........................... ..... -- .: ..................... 1._. ... _.. ------------------ . ...------- - - Dat - -- --._.._:__,_.: ' T' Final Inspection by: e-# �.. ._..... _ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H- 13 24 I-.68 ups- _gm 7179-3 M