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FOIL OFFICE„USE: .. APPLICATIONaFOR_SANIT TION PERMIT t x Permit Na- -------------- ----- (Complete in Triplicate) ' Date Issued e j '+ -------------------- _-- This Permit Expires 1 Year From Date Issued I Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the. work Jierein described. This application is made in complianc with Caunfy Oralinance No.-549 and exisfing_Ru1es'_and Regulations: ; , JOB ADDRESS/LOCATION .- �/ yl1=h ----------- -----------------------------CENSUS TRACT ------------------•-• --- t Owner's Name 1 Ct Ids- fl - = ' --- ----------------------------------------- ----- -- Phone --------------------------- ....... __ 177 Address --------------------- - --------------------------- City G ----J---------------- -------------- y /� Contractor's Name ----------- -- e1'YJ License #/'�� ._ Phone i� Installation will serve: yResidence uAllatment House!❑ Commercial :❑Trailer Court ',❑ ' Motel ❑ Other -------------------------------- ---------- Number of living units:---- Number of edr oures _ _Garbage Grinder f�f ___ Lot Size ------------ ----- Water Supply: Public System and name __ __-__-- - •- •-•• t L }� -------------------------•---------------Private E]Character of soil to a de �```�of 3 feet: Sand'❑ tt❑ Clay Peat E] Sandy Loam -El Clay,Loam EDpth Hardpan ❑ Adobe' Fill Material _.,/Y�__ if yes,type ________________._____-.___ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) is tank or seepage. it permitted if public sewer is available within 200 feet,) NEW INSTALLATION: (No septip p p ` � PACKAGE TREATMENT [ ) SEPTIC TANK;�] Size-4_,— ize_ _ _ -- -X-- -�-%.-------- --------- Liquid Depth I- --------.----- Capacity __ --___ Type /]� Yr--- Material-- �. No. Compartments _ ______________ Distance to nearest: Well ------lti s_______________Foundation -----/L----------- Prop. Line - ........ LEACHING LINE [1j--�No. of Lines ------ ------ Length of each line---1,_t?t?-1--------------- Total Length -J-04!............. 'D' Box ; !g----- Type Filter Material epth Filter Material _`_ _--------------____________________`-;^: 5 Distance to{nearest: Well __________________ Yes �No ❑ Foundation _--J- ------_-- ----- Property Line _ SEEPAGE PIT [ Depth __ :____-_- -Diameter ,�_�•-_______ Number --._ __ _____ __ ________-___ Rock Filled 44 Water.Table Depth ------------------------------Rock Size -- - - '3- r 1Foundation r Prop. Lin ------------- t I. r.- ------------- Distance to nearest: Well ________ _______________ - REPAIR/ADDITION(Prev. SanitationDate ----------------------------------} t • , SepticTank (Specify Requiremints) ----------------------------------------------------ii--------------------------------------- ------------------ ---•------------------------- Disposal Field (Specify Requirements) ---------- ----------------------------- ---------------------------------------------------------------------- i e ------------------'--------------------------------------------------------------------------------_-----------------------------------------------------------------------------------------:----- I I-(Draw existing and required add iti&"n reverse-side)- k 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. Home owner or licen- sed agents signature certifies the following: 4 ; r "I certify that in the performance of the work for which this permit is issued,J shall,not employ any person in such manner f as to become subject to Workman's'Compensation laws of California." Signed -------' --------- ---------------------- -------------------------- Owner By - --------------------- - ----' --- -------------- ---- -- �---------------- _ ---------- -- ---------------- - - ' - ;;- - ----------------------- Title �'l-`f� , (If oth' r th n owner � FOR DEPARTMENT 175!! ONLY APPLICATION ACCEPTED BY _ _�_ _____ i DATE = ------------------ BUILDING PERMIT ISSUED -------- --------------- ` ' __DATE ADDITIONAL COMMENTS ------------------------ -- ------------------------------------------------ --- ------------------------- ----------------------------------`----------------------- --------'---------- - - ----- ------- --------------------- ----- -- -- - -------- ---------------------- ----------- ----------- ----- -"------- -----------------'-- - -¢ -------- ------ -- -------------------------------------- ------ Final Inspection by: f --------------------- Date / JOAQUIN' LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ~