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7:7 R OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. - 6 --- `' (CompfeteinTriplicate}---- 7 ------- .y Q T� i ! Date issued �----- -" --� This Permit Expires 1 Year From bate Issued ---------------------- ----------- ---- -- ---- :------------ with County Ordinance No. 549 and existing Rules and Regulations: Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the war herein pp described. This application is made in romp CENSUS TRACT - - JOB ADDRESS/LOCATION Ar- �< , ., ---Phone ------------------------------------ - I d ----- -- --------_-------- -------------------- GOwner's Name . --- - - - --- - -- ---•- ----- City � ----------,-�---------- -- ------ ------ ess - AddrLicense Phone _rr I Contractor's NameQ = "" i Residence '❑partment HouseCommercial []Trailer Court Installation will serve: ',❑ Motel ❑ Other -------------------------------------------- ---- ---- ---- ---- ----- ----- - -- --- _- Lot Size `�--.�f��'�-� -------------- ----Garboge Grinder e';> Number of living units:-". --- Number of bedrooms - Grinder/e';> ------------- ---------- Water Supply: Public System an name ---------------- Peat❑ Sandy Loam 0 Clay Loam y .. , Character of soil to a depth of 3 feet: Sand'0 Silt.❑ Cla ❑ if es, e Hardpan Adobe.❑ Fill Material -�------ Y tY17 rbuildings, etc. must be placed on reverse side.) of system in relation to' wells \ (Plot plan, showing size of lot, location , , it permitted if public sewer is available within 200 feet,) NEW INSTALLATION: (No septic tank or seepage p p ; - %—.4 Depth "' ------- ---------- TREATMENT { ] SEPTIC TANK'[' Size---- - PACKAGE _-_ No. Compartments ----2--' i Type - 44- Mafienal" i1' , s Capacity . �� ,.� --- Pro Line ---e__ -------•--- k ---------------•Foundation -_/�----- -- p• ,. Distance to nearest: Well -- -- ----------- Length of each line_-- Total Length .4d"--e-------•----•- I LEA CHINE L1NE `� No. of Lines ------- -------- '' !^ -De th Fiilter Material - �------------ - " '" " ' D' Box E.'--z- Type Filter Material p Foundation Property Line. ----------- --•- Distance to nearest: Well __�`�------- -- - - ---------------- s 1"/_ Number ..... Rock Filled Yes No _ Diamefier ,�� 2�-- """-"" ---- SEEPAGE PIT �Q Depth -- sy `�i - � Rock Size - 'p Water Table Depth .... --------------------------- ---------- Prop. Line -----• -"i Distance to nearest: Well ---- --------------------Foundation -. -.- -- k L# Date ----------------------------------) t� REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- - "-- ------ ------------- ---------------------_ Septic Tank (Specify Requirements) -------- ------------------------------------- ----------- Disposal Fieid (Specify Requirements) "----------------------- -- ----- ---------- ' �- ` ------- ----------------------- ------ ------ --------- ------- " ` ..---- (Dra existing and cation and (that dhetion on reverse side) i. �'+ -- work,.will be done in accordance with San Joaquin I hereb +certify that h ha a repared th pp oa uin-Local Health District`. Home owner or licen- County Ordinances,, State Laws,�and Rules and Regulations of the San J q sed agents signature,certifies the�following: person in such manner "I certify that in the ,performance of the worts for which this p ermit is issued, I shall not employany as to become subject to Workman's Compensa' n laws of California." � I Owner - ----- ti Signed i ---------- - --- ------ ---e--- Title ---- ...... --- -�- -- - = ` (If oth n owner) ! Ti t FOR DEpAATMENT USE ONLY t: ¢ DATE -.j-d APPLICATION ACCEPTED BY ---- _ ---- --- - -- ------ - BUILDING PERMIT ISSUED ------------------- - j ----- ---- .----- ----- ---------__ ----------DAZ� --------.------------ ADDITIONAL COMMENTS ---------------- -------------------- --- -------- ---------- __ G --------- '`�� - f�JfJ" �} ---------- Date --------- Final Inspection y: ---- - --- - , SAN JOA UIN LOCALS HEALTH DISTRICT 8 Rev. SM i �,� `:>r t."` . .i ,:. �I. S` -' _ E. H. 9 1-'6 4 a