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FOR OFFICE 415E: APPLICATION FdR SANITA't`iON PEWIT ......................................................... ;w ( a, in Triplicate) Permit No. �6. 6Y Val .. . ....... ...`. . .I.......... This Permit Expires y Year From Dat*lsswee! Date Issued .P...:y...j� s Application is hereby made to the San Joaquin Local Health District fora permit to construct and Install the work herein described. This application is made In compliance with County Ordinan'e No. 544 and existing Rules and Regulations JOS ADDRESS/LOCA ION ......� . . .... .................. "�� CENSUS TRACT ... .. ............. Owner's Name .. . n17. ..... �. ......... : .. ....... .... .... Phone .Z.4- c24153...... Address .................... ...... .... ......... ...City ..Msaxa c)��. Contractor's Name .... p.- .:.... .. J ...... ................License# .cX.p,l9s � .. Phone :If a installation will serves Residence WApartment House C)Commercial C)Trailer Court 0 Motel❑Other ........................... .. Number of living units:............ Number of bedrooms Garbage Grinder Lot Size .��401eG ......... Water Supply: Public System and name ................... ............ _........ i ....................................................Private ❑ Character of soil to a depth of 3 feet: Sand� Silt OClaY O Peat dSandy Loam fl Clay loam Q Hardpan Adobe Mit Material . .........If yes,type.. ......... ............. Q (Plot plan, showing size of lot, location of system in relation to_weils;, buildings, etc. must be placed an reverse sida� NEW INSTALLATIONa (No septic tank or seepage pit permitted if public sewer is available within 204 feet,) \ PACKAGE TREATMENT ( j SEPTIC TANK{ j Size.../4 1 .Y.. P.............. liquid Depth ..... 2............r Capacity ,� �..... Type/&. . Material . .... No. Compartments ....�... Distance to nearest: Well ......_. 1.Founclation ..../V............ Prop. line ..Z ... LEACHING LINE No. of lines . . ............. Length of-each ..:.............. Total length ...ra�i.lf.� ..... Box 'D' / ....1..... Type filter Material ../. LDepth filter Material .....J�............................. • , Distance to nearest: Well . .................... Founddtion ........................ Property Line ...................... th ............:...... arneter .............:.. Nu or ........................ Rock-)' Yes ❑ No Q �..�... .o Wale b!e Depth .Rack ... ...... Distance to neares : oil ..........................................Foundation .................... Prop. Line ........._........... REPAIR/ADDITION IPrev. Sanitation Permit# ... pate ................. . ........ .) SepticTank f Specify Requirements) .......................................................... ...... .........».........................................._..... ........ Disposal Field (Specify Requirements) .......................... ....... ....... .. ................................................................................. ..................................................................................... ........ ................. !. .............................................................. . .. ....... ..................................................... ........................ .... ... ��i ..... ..................... .............- (Draw existing and required addition on reverse side) j 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 lite& j sed agents signature certifies the following- "I certify ollowing:"I.certify that in the performance of the work for which this permit Is Issued, I $hail not employ any person in such manner as to become subject to Workman's Compensation laws of California."' . it Signed ............ .. .�.... .. .... .... ..... Owner a By.. . .. . . ... ................ xitle ............................... Of other than o or) . I. FOR DEP TME T U ONLY APPLICATION ACCEPTED BY... ..... ..... DATE .... ....................... f3UiLDING PERMIT ISSUED .' .. ....D TE ................... ADDITIONAL COMMENTS ......:........... ... ................. . .............................................................................................................. . ... . ................................. ....................................... .. ............................................... .......................... .................. . ................. .... .. Final inspection by ..Date . ... T.J. v.. �t :.f . .,: . . .... EH 13 24 1-68 . 5M SAN JOAQUIN LOCAL HEALTHI DISTRICT $/7!t 3M Yf