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(Comptefe In Triplicate) Permit No. ...... .. : .................................... Tbls Peroilt Year From Date Isswd Date Issued . .::.......... r-Mon is�ereby made to the San Joaquin Local Health District for a permit to constrvd and Install the work herein d. Thii'opplication Is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: DDRESS/IOCATtON _...__�.-..eC..... r-•-------------CG/.�� .... 1`-y __... _ .........:.......CENSUS TRACT .......................... , s Name -_. et� ........p-c �........__._-------»-----------•..................................Phone ............................... ...............city G, , . ..............................................».... Ftor's Name _................._.---._..-_-...........License Phone tion will serve: Residence Apartment House C] Commercial QTraihw Court Q Motel Q Other »»..» r of living unitss_:.j------ Number of bedroom; ..__Garbage Grinder ..........,. tot Slee .. �� ......»... iupplyr Public System and name ................... .._...._ ......_..-.-,...__. ..... ..........�...--...._._..__.�.--_lrrivate r of soil to a depth of 3 feet: Sand[3 Silt Q Clay ❑ Peot Q»-«Sandy Loam 0 Clay Loam Q Hardpan Adobe❑ Fill Material . .If yet,type- i n, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] -iSTALLATiON: INo septic tank or seepage pit permitted If..public sewer is available within 200•.feetj 3E TREATMENT [ } SEPTIC TANK f ] ,gyp Size. �.�f'. ._..»_..»... Uquid Depth ..t?.Y..............)_ . Capacity ------- Type %Material. »..... No. Compartments .. _ . »..J Distance to nearesh Weil _�C '..�:, .-..,..---.foundation_......»......----». Prop. Una .»__».__-3 �G LINE [ ] No. of Lines ..,,7................ Length of eeac_h_Il`ne----',TrGS�..........._. Total Length / 9.....»:...... m rL i 'D' Box .�..... Type Filter Material r/.�Y _�Depth Filter Material . .f ��.............. .1......... Distance to nearest: Well/.�..�... . Foundation,1..'�:r.......... perty. ProLine .��.`..........� [-,E PIT [ ) Depth .o?�� j......... Diameter Z3 ...... Number ....... .___..__.._..... Rock.Filled Yes No Q•- Water Table Depith ............... Stns ...... .....»...»..- ro Distance to nearest: WellFoundation . ..-............ Prop. Une ._..... . 'rrADDiTEON(Prov. Sanitation Permit# - _--....»..................__.. Gate ..«.. ��_..] c Tank(Specify Requirements) -------------•-- .............. »,..».....»»»...... ..._............_........... »..� Psol Fiela (Specify Requirements) .......... .......................-......-...... ...._._...-............................................................... r ' - (Draw existing and required addition on reverse side) .-- _...._.......---•............... i V.certify that I have prepared this application and that the work wilt be dote M accontancs with Son Joaquin Ordinances, State Lows, and Rules and Regulations of the San Joaquin Local Health District. Homs owner or licen- Fnts signature certifies the following: y that in the perforTance of the work for which this permit Is Issued, I shall not.employ any person In such manner tcome sub at to r njdn's Cpens on laws cif California." .. ..._. . ' ._... !-,. ._......- --_................................. Owner +...._...•.. .... ............... .....•--....--•---•-•-•---......._._....._...._. . Pie .......................................................................... (if other than owners k '' MDEPARTMENT USE ONLY 4TION ACCEPTED BY ... ......._...... ............................ .-� .� ......:..........:.: �--JG PERMIT ISSUED ....................... ..................:....._........_......_.._.......... ..........._, DATE _....:...---_... - ._,. _ _DATE.......................... JNALCOMMENT5 ......... ........._................-...............................................:...................•.. [:. ............................._.-_.__.._._.._-_••--......•. ............... ............................... _..... ... •.... .... ...................... ........._................_. ._. ......--_........ ._... .... . - / ....- .. . spection by: . _.. . -.........Date // .................. 7h 1-68 Hay. SAN JOA�UIN LOCAL- HEALTH DISTRICT g/?. 3H ;.