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FOR OFFICE USE: . ppp�IGATION FOR SANITATION PERMIT Gl•_/ 3 'Pe'rmit No. ------- --------- ------- (Complete in Triplicate) ---- w, � /p2r5r� Date Issued This permit Expires 1 Year From bate Issue it to and e work rein Application is hereby made to the Son Joaquin iancecwitheCou alth District for o �1om549 and ex sting Rulestand hRegulat ons.. described. This application is made to p CENSUS TRACT ---------------=---------- JOB ADDRESS/LOCA ON ----- ------------- ��'� = 'hone - -- Owner's Name __ - - �� -..`t : J --,-- ------ -------- -f -- City _ - ---- Address -- --------------- --- - ------ .License -------------- ----------- Phone �------- � _ # Contractor's Name - --- ----------- - ------ --- - ---- ------------------------- -- - Installation will serve: ResidencexApartmenfi House❑ Commercial ❑Trailer Court Motel [:] Other - -:----- -------------------------- ---- Number of living units:.--_.1 ---- Number of bedrooms -__-\Garbag Grinler __---- Lot Sze _.__---------------- ' ---------- ---- -Private ❑ Water Supply: Public System and name __--------------- --- Clay Loam ❑ IF Character of soil to a depth of 3 feet: Sand'❑ Silt❑ ` Y'`❑ Peat❑ Sandy Loam •❑ Hardpan E] Adobe)},Fill Material ------------ If es 4 typ Plot fan, showing s ze of�,fot, location of system in relation to wells, buildings, etc.i muse placed on reverse side.) { p '-�p � "'� ermined if public sewer is available v'�ti#�ghin 200 feet,l NEW INSTALLATION: (Ndls+ tic tank or see age p'tt permitted P P. Material .No. Com Depth - Liquid PACKAGE TREATIU�1(N� [ ] "5EPT1C TANK'[;] F =. ` payments lcapac y�'-- -• Type ---- ! Distance to ineaarest: Well ------ Foundation ----------------------- -- ---------------- Prop: Line ----------=•---------- r ---- nth ----------------•------- Len Length of each line--------------------- -- Total ,Len . i No of Li 9 v LEACHING LINE [ ] f 'D' Box -.------- -- Type Filter Material �;: -----= -Depth Filter Material ' ,,V M � '. �� j•- Property Line - - oundation -------- =------t-�----- p �Y Distance to earest1Ne11 --____--------- No.O I SEEPAGE PIT [ ] Dep#h _-_---.-�_- -,-'��tAeter ---------------- Number' ----"-------- Rack Filled Yes �] �—�- Rock Size -------'--------------- ------ Water Table.-Dept-h�---t-�_----------------------------------- Distance to nearest: Well ----------------- Foundation Prop. Line = Date ---------------- -----------------) REPAIR/ADDITION'(Prev.r,Sanitation Permit ------- ------ = I1 ----------------------- ------ ----- ----------------- Se tic Tank (Specify Requirements os Fiel , pecify Requirements ---•-------------J ----------- -- • ' - -- - -- - k � - ditioronire er de) (Dr a ing nc r u P e '� � �c i n n t�e"�Iffo'rk s i o e i accordance with San Joaquin I hereby ce ify tha I have p pare is pp tions of the an�!Joaquin Local Health District. Home owner or licen- County Ordinances, State Laws, and Rules and Reguu � ft ; sed agents signature certifies the following: C r 1 certify that in the pe rformance of the work for which this �ermit is issued, I shall not employ any person in such manner f as to become subject to Workman's Compensation laws oCalifornia." Signed ----------------------------- -------- --- - ----- ------------------------------ Owner ' j -------- title j a�A i BYIf of er n owner) 6 i Q PARTMENT USE ONLY APPLICATION ACCEPTED BY ------ y ------------------ ------------------------ DATE ------. ---` DATE - ---------------- - BUILDING PERMIT ISSUED ---------- - -- ` - - --- ------------------- 1 --------------- t ------ ADDITIONAL COMMENTS -_____-- .----------- = ---- ------ ---- ----------------------------------------------- ------------------------------------------------------------ -------------------------------------- -- - -- - - ---- ------- -------- � ------- ------ I -------------Date --- Fina! Inspection b -- --------------- -------" " UIN -LOCAL HEALTH DISTRICT4Y r E. H. 9 1-'68 Rev. 5M