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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. - --------------------- ----- -- (Complete in Triplicate) i Date issued ---------- ---------------------------------------------- ----------------------------------------------- --- ----- - This Permit Expires 1 Year From bate Issued l the work kpplication is liereby made to the San om lance Local health Counttytrict for a permit to construct and-ordinance No. 549 and ex st ng .Rulestalnd Regulations rein described. This application is ade in comp s+'17 f�. CENSUS TRACT . JOS ADDRESS/LO .TION Phone -------------------------------- -------------- Owner's Name _ - --- --------------•------------- Address C'� ' b_ - one ------ -------------•------ - - _: =s--- Ph Contractor's Name ____- � ------=�'-'- --.License # --G.��_, Z�- -- Residence Apartment House❑ Commercial ❑Trailer Court 0 Installation will serve: Motel ❑Other ---------- --------------------------------- ? ---- •----- ---- Number of living units:_-.-_I____._ Number of bedrooms --::-3----- Grinder ___----- --- !!o't Size ---- s�-a- - _ Private Wafi er Supply: Public System an name _____________________ ___ --------- ------------------------------------------ Clay y Peat❑ Sandy Loam Clay Loam ❑ I Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ,4, � I Hardpan ❑ Adobe❑ Fill Material ------------ if yes,type (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) it permitted -+f public sewer is available within 200 feet,) seepage p p i ------ Liquidm _ _ NEW INSTALLATION: (No septic tan or �/// ''Depth __4/-----------•---.----- SEPTIC TANK'[ 5ize-7h X PACKAGE TREATMENT { ] �e `t " Capac�t�r :�- �06.G - Type 1 _ _ Material_± -------- No. Co partmenis Distance to neare Well __-_---`S©- � - -------.Foundation ---�------------- Prop. Line ----•------•-------•-- ------ ---_ ------ Length of each line------go-------------- Total Length _-�-F - _LEACHING LINE [" No. of Lines - g rr 'D' .Box - --- Type Filter Materia! _--- -�_- Depth Filter Material _------�-- ~� ---------- Pro er Line -------•- ----------•--- i Distance to nearest: Well .....N!So.-------- --- Foundation -----A--- p Depth ----- Diameter ---------------- Number _ .-- _ -- -------- Rock Filled Yes ❑ No i❑ SEEPAGE PIT [�] p ---- �---�- - - - - - '�� -Rock Size ------- ------------------------ Water Table Depth -------------------------------------------- -- Distance to nearest: Well ___----------------- -- ----==----- Foundation ------------w---- Prop. Line ---------------------- Date 1,%4,- ----.-------- ------------- REPAIR/ADDITION(Prey. Sanitation Permit ---------------------- le, Septic Tank (Specify Requirements) ----------------------------------------------------------- ----------------------------- -------- Disposal Field (Specify Requirements) ------------------ - �- A F Y ------I----------------`----------------`------------------------------------ - side3 ------- --- f - (Draw existing and required addition on reverse uin I hereby •certify that I have prepared this application and that h San work will be done oal Health Distin rict.nHomece 'townef oh Son r licen- sed County Ordinances, Slate Laws, and Rules and Regulations of q , sed agents signature certifies the following: I "I certify that in he performance of the work for which this permit is issued, I shall?not employ any person in such manner as to become subject to orkman's Compensation laws of California." i ` Owner Signed -------- } e,_12-71711 1 � . LGL fBy --------- - (If other than owner) 4 FOR DEPARTMENT USE ONLY Q DATE ------------- --- APPLICATION ACCEPTED BY -- - -- - - ------------ - -----------DATE ---------------- -------------------- •---- BUILDING PERMIrf ISSUED ----------------- ------------------------------------------- --------------- - ADDITIONAL COMMENTS ------------- ------------------------- ---------------- ------- ------ --------------------------- �- ---- ------------------------------------ ---- ----------Date- - ------------ - - -f j"- tea- _ -------------- - - - - --- Final Inspection by: - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M