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LOROFFICE USE: jAPPlICATION FOR SANITATION PERMIT Permit No. - "" (Complete in Triplicate) 4 - -X e---- ------ Date Issued .1�--^=- - / . ' This Permit Expires 1 Year From ),ate Issued with County Or in ce No. 549 and existing Rules and Regulations: Application is hereby made to the San Joaquin rLoetal Health District fora permit to construct and install the work herein pp described. This application is mdde in comp , 3 �" = -------- - CENSUS TRACT .f JOB ADDRESS/LOCATiO ------ ------ 6 -- ��' E _ ---- ----P one�=----- -=------ - -- - ------ ----- Owner s rName - ` 6 / C Y - . t Address License # Phone - - - -- 11 Contractor's Name ._-" ----- ---- "--•- ----- --- i o lnstallori will serve: ti Residence ❑ Apartment House❑ Commercial ❑Trailer Court s Motel ❑Other - e � -- Lot Size ---- --------------------------------- - Num er of living units:--- ------ Number of bedrooms arbage'Grin els--- -.j� f---------------- ------Private ❑ S ----- P Water Supply: Public System and name ----------- eat❑ Sandy Loam .❑ Clay-Loam :❑ Charact of soil to a depth,of 3-feet. Sand`❑ Silt❑ Clay- ❑ -------- ------------------ (Hardpan E] Adobe Fill�M,lat�I ------------ If Yes,type _ 1 ,• NA . rte, `_`�.f # buildings, etc. must be placed on reverse side.) (Plot pian, showing size oation f;lot, loa on or` stemin& fg' e�°fUil sewer is available within 200 feet,) NEW INSTALLATION- (No septic tank seepage plt pe _ u -- Liquid Depth Size---- ---- ------ - -------- ---- •----- PACKAGE TREATMENT [ ] SEPTIC TANK.1 ] W p --------=---• I Capacity jYE�e� Mat ial----------- No. Com artments p y :--------- -- Prop. Line ------------------- I N 'Distance to:. nearest: Well ----" - --Foundation --------------------- !: Tota! Length ----- No.'of.Line � Length of eachame_�„,:--�.�•- "" -�-•"--- LEACHING LINE [ ] --" -- s Depth Filter't Material -------------------- -------- -------•------ "D' Sox ._- ----- -Type Filter Material -"�--- -;�-- ------- Property Line. ---------------•--------- Distance tto nearest: Well --------------- Foundation ------------ Rock Filled Yes ❑ No i❑ - Diameter -------------- N.umber ------------------ SEEP PIT [ 1 Depth 1" Water Table Depth ------------ ---- '=----------- --•='._Rock Size --- ----- ------------------•--- . ---------------Foundation Foundation Prop. Line ----- Distance to nearest-. Well �� -�------ - ��` Date ----------- ) REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------= --------------- -------_ _ ----- - -------------- ------------- Septic Tank (Specify Req - '. - --_-(��----�""� -------------- - -- - Specify Requirem ts) ----- iDisposal ... - ---- ----� Field F f Y ._, -------^ j I ------------------- ------------------- 1 ------ - ------ ----------------------•------------------------------------------------------------ (Draw existing and required addition on reverse side) k ce wih San Joaqu I hereby certify that I have prepared this application and that he 5 n Joaquin local Health D'strrk will be done in c County Ordinances, State LawtnHometo ner ar I cen s; and Rules and Regulations of t sed agents signature certifies the following: erson in such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any p as to become subject to Workman's Compensation laws of California." Owner Signed --- --- --.- ------ Titler --- =.:r te?a~ " 5i BY (if other owner) FOR DEPARTMENT USE ONLY DATE "" ---� --------- ---------------- ------------------------------------------------------ ---------------------------------------------- DATE -- --------• ---------------- APPLICATION ACCEPTED BY "- C `� Y ""�-r_ ------ BUILDING PERMIT ISSUED ------------------ ADDITIONAL COMMENTS ----------------------------------------------- ---------------------- - ----= ------- - - ------------------ - --------- ---- -- - -------- --------- Date ---3 S Final Inspection --- d ---- --- - by: ------------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M