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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: --- -- t (Complete in Triplicate) -------------- --- -------- --------- - <.- Date Issued �a----��---�---]_.�. --------- -------------------------- i y This Permit Expires 1 Year From 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. 549 and existing Rules and Regulations: ' CENSUS TRACT -------------- ---------- JOB ADDRESS/LOCATION ---- --- -- }i ��,��•..-.,,...�...:,..._ . . -•-..-..,.��,;t __.Phone --l-�f.� Owner's Name -------------- �'---------- ------------ ............ Address _.------ 3 City nr/ f . ff License # _ � _ �._ - --- Phone `fib - Contractor's Name ..__- --_-- ----------------- -- ---- - ---- , %�`GTF----------------- Installation will serve: Residence Apartment House❑ Commercial;[]Trailer Court i❑ Motel ❑Other --------- -------------------------•-------- .� Number of living units:-----1_---- Number of bedrooms ________Garbage Grinder ------------ Lot Size ________________ —<__.___..____. Water Supply: Public System and name -------------------------- -----------------------------------------------PrivateX Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ Hardpan ❑ Adobe)4 Fill Material -----.------ If yes,type ___________________________ 6N [Plot plan, showing size of lot, location of system in gelation to wells, buildings, etc. must be placed on reve se{side.) O I - NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is dvalable within 200 feet,) PACKAGE TREATMENT ] SEPTIC TANK' `i ze_____________ __ ` - Liquid Depth --- �_---" -s ---------- f' • ? + - q P �. -- Material__ GW=-- No. Compartments. ___ _ i. Capacity�& : - Type -- ------- f----- � . -- �� Distance to nearest: Well _ -�7 -- � ------------Foundation ___�_O___:-`___ .Prop. Line = `�.----i----: Y LEACHING LINE' No. of Lines --_-df��--------- Length of each line Depth Filter Mat riaialµe - -------------------------- 'D' I Box _____ --- Type Filter Material ------_• P --/Ck--�---4__-Pro er Line: _ Distance to nearest; Well --�__�; ----- Foundation P tY r � - �/ Rock,Filled Yes. No !, SEEPAGE PIT Depth --- --- -- Diameter --------- Number - ----- ---------------- _ Water Table Depth - ---- IL i ' ~' -.. k- Rock Size _ . _- .Foundation ---1-0-r' `_ 'Prop. Line _... -------' -- Distance to nearest: Well ----�--0Q----------- --------t--.. _. ._ � - REPAIR/ADDITION[Prev. Sanitation Permit Y# ----------------------------------------` Date ------•-------=----------------- 1 f' ----- --------------------------- Septic Tank (Specify'Requirements) __ :_. _- -- ------------------------ Disposal Field (Specify Requirements) ----------------- ------------ ___ -------------------------- ------------------------------------------------------------------ ------------------------- # (Draw existing and required addition on reverse side) I hereb certify that 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: "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 subie'd to Workman's Compensation laws of California." Signed Owner ____________ ___________ ___"______ ----r_______ ------- -}- ---�----`- ;title ` ----------- I (If other n owner) t 1= EPARTMENT USE ONLY APPLICATION ACCEPTED BY ______ DATE _. ---f.�= -------•--------- -- - - - -- --- -- --------------------------------------------------------- BUILDING PERMIT 155LIED ------ - ---°-------- -----DATE ---------- ----------- ---------- -----•- ----- --- -- ADDITIONAL COMMENTS ----- -- - -- --- - -------------------------------------------- ---------------- ---------------------------------------- ------------------------------------------- --- ---------------------------------- --- - ---- -------- - Final Inspection by: ------------Date ---- --'- =�� '=--------------- SN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 ° 1-'68 R . 5m ,'i t 41#