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FOR OFFICE,,USE: -"' APPLICATION FOR SANITATION PERMIT !4 Date Permit -y (Complete in Triplicate} ---------------------- �_ Y �; . ��' This Permit Expires 1 Year From Date Issue ------------------- ------------------- , , . Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein Rul described. This application is made in compliance with County Ordinance No. 549 anp�e�xti RuE�end f9t{ons �7. w Y � !✓� CENSUS TRACT --------------•----------- JOB ADDRESS/LOCATION .��f('-1-- - ----�-------------------Phone ��4--��-_�.__�_. y Owner's Name ----R_4-------�AXPl - -------- �,� ----- ------------•--. City /�d`I��<`�_------------------------------------------------ Address --------- -------------------•------- Address ,r .r91�1Q- = �15 ----- - xw Contractor's Name --- - ------ -------------------------------- License a2 V- Phone --------I- I installation will serve: Residence OR-Xp'cirtment House'E] Commercial ❑Trailer Court Motel ❑Other ------------------------------------------ € - Lot Size J��__ � --------------- Number -------•-- . Number of living units:___ ------ Number of bedrooms-3-------Garbage Grinder t Pri ate Water Supply: Public System and name -----________"-- Peat❑ Sand Loam ❑ Clay Loom :❑ Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Y Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ------------------------- T -- -(Plot•-plan,-•-showing-size-of-lot,-Iocation•of-system-in-relation-to wells;,bbildings, etc.kmust.be-placed-.ora-reverse side.) r NEW INSTALLATION: .,(..No septic tank or seepage pit permitted ifspublic ewer is available within 200 feet,l df �_ / q- -X--�9.�---X��----------- Liquid Depth _��-----------.----- PACKAGE TREATMENT �[ ]{ SEPTIC TANK![A Size_ ! tF Material 60151 ., No. Compartments - = Capacity �� TYp - ----�-N -------Foundation __�@ Prop. Line ------- Dista to nearest: Well ___ �---- ---------- � LEACHING LINT No, of Lines ^----------- Length of each line---- Total Length -- ---• 7 4 °'""" D' Box VE'- - Type:F"ilter Material p > -------Depth Filt r Material __ __------------- ------- -- I - Property Line - p ty No ❑ Distance to nearest: VGell ��----�----- --- Foundation _----.---------- - ] ---------- Number._ .. -- _-_____.___ Rock Filled Yesi [] SEEPAGE PIT. '[ ] Depth _ � -w;-----�- Diameter ------ t i R ! _ ock_size ____________ _____ ------ tr't Wate ai ble De h 'ti--=- • Line . Distance`to nearest: Well ----------------------1Foundafiion ________------"-"--- Prop k� y . . � -I. Date ----------------------- ---------1 I REPAIR/ADDITION(Prev. Sancta on Permit# ------------------------------ '' h ,, ------------- -- ----------- e uirements]r�_.__. ._ ------ Septic Tank (Speci.Y �� _ 1�_..�.— .._-. ..., lci Re, iremerits Fie p fY q ------------------- Disposal ----------- { :.. ----------------------- ---------------------- -------- - --------------- k -------------- � ------------------------------ - --------- �- ,fit:'::r (Draw existing and required addition on reqverse side) application and that.the work wd0 be done in accordance with Sang Joaquin I hereby certify that I have prepared this app i County Ordinances, State'Lavvs^and Rules and Regulations of the:San Joagyin Local Healtf� District. Home owner-or licen- i € yI sed agents signature certifies the following, tVc "I certify that in the performance of the work-for which this permit is issued, I shall not employ any person in sh manner f as to become subject to Workman's Compensation 11jw%ss of California." ._..._ _ �. -._�v_- - . -__ T Owner 11 t Signed --------------- ------ - --------------- _ By ---------0 �� e47& X_. 4 t__�'1'" --------------- -------------- Title,- . ------------- (If other han owner) l FOR,DEPARTMENT USE iONLY s �' DATE __.u _�----� APPLICATION ACCEPliED BY ,..^ _..------ --- ------rte _ _ � � BUILDING PERMIT ISSUED __.-"'_"------------- ADDITIONAL COMMENTS __f -`�-. 't f '''� f'`� x '' - ----c-�--'----- --------� ----------------- __ ----- f + ------ --------- --------- ----- ---- ---------- ---------------------------------------------------------------- ------ - ---- ---------------------- -------- - ------------------------ -------------------------------------------------- - - ------------- Date - - ------ -------- -------- Final Inspection bY:--- - - -- ----- -------------- ---------------- ---------- --------- --------- ----------------- - SAN.JOAQUINJOCAL.HEALTH-DISTRICT-��...,... -- ;-- ...�._.-.�..--.._ �.�...�. ..+ ...... �....�._� -. :-.,..•-...�-.. ,....r.....rte•-.,...,.....�.�.�,.Y- E. H. 9 1-'68 Rev. 5M