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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ......................................................f_. Permit No. {Complete in Triplicate} ............•----------- -- -------- This.Permit Expires 1 Year From Date Issued Date Issued 2:7�/ ..9 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..... .f� 1 .... ....../ G/? .._.. u_------- - ....CENSUS TRACT .....5..i . .. Owner's Name ............. pG/1!... _ .............................................--.Phone .................................... Address ...............-... --�9�'9_� ---...............................................................•._. City ........................................................................ .... a �O 1V /°� .5 '6... Phone ..........3.I.`..� i� Contractor's Name /�n�----�i-__. __._..License # --------------- Installation will serve: Residence aN Apartment House❑ Commercial:❑Trailer Court Motel ❑Other ........----............................ Number of living units:.._. ..... Number of bedrooms ?.......Garbage Grinder ------------ Lot Size Aq__A�.Yes Water Supply: Public System and name ---------------------------------------------------------.....................................................Private Character of soil to a depth of 3 feet: Sand❑ .Silt❑ Gay ❑ Peat❑ Sandy Loam Clay Loam [I-- Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- (Plot _________________________(Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. ust be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepag i pit permitted if public sewer is ovailak le within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size........................................... ... Liquid Depth ........................... Capacity ................ •-- TY ----•----...... .... Material--------------------- o. Compartments ---..................6 Distance to nearest: Wel ....................................Foundation ..----- -------------- Prop. Line ...................... LEACHING LINE [ ] No. of Lines .................... ... Length of each line---------I—..........._ Total Length ........I..................I 'D' Box .---------.- Type Filti r Material ....................Depth Filter M erial -----------------------.. .................. . Distance to nearest: Well ----------------------- Foundation .... Property Line ._............ ......... SEEPAGE': PIT [ 7 Depth .................... Diarr ater ................ Number __._.__._______........ .... Rock Filled Yes ❑ No C3 Water Table Depth ....... .......*........."..............Rock Size Distance to nearest: Well ........... ...Foundation ... .. Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ------- --------------------------------- Date ..................................I 1 SepticTank (Specify Requirements) .._....--•-- -----------------------•------•-•------•-------•..................--•--•-•-.............._.....------------------------. Disposal Field (Specify Requirements) ----i!te. 17,f1_A.....&C.1.5.!'... .?fy? -------kcgj � ..... �. .C...__p .......... y CPQ --- �:....3(-A......�it/f-�r� .......... ... ----- ------------------------------------- ..__w-......... ------....--------------------•---------------------._..............----...-- (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." Signed .. ... /f rl+ o:N�/--`f_.-. Owner T BY ------------------------------•------- ----------- Title ------------------------ (I o er the awns✓) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..---�f.i .4 ......................... .............................. .............. DATE _._..�.- ..�."-7-- ---- BUILDING PERMIT ISSUED ................................. ......................\.....:....._..............-..._.._..........--- DATE ...---------.............. ---------------- ADDITIONAL ADDITIONAL COMMENTS .......... ..................... . - :....._...... ....... •--- ......-- ----•------- ----• -•................. --- ........ ......�- - .............•-----.......... e -.e.....:............ ...._. Final In !c ' - ---• --•--.:...._.Date -- -•'�..... .............. ............ SAN JO,kQUIN LOCAL HEALTH DISTRICT E. H.1.3 24 1-'68 Rev. 5M - 7172 3 LK