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FOR OFFICE- USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: # (Camplete in Triplicate) Permit i ............ --------- "-".................... } This Permit Expires 1 Year From Date Issued /- Date Issued..67._:1....?� application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ~ G JOB ADDRESS/LO ATfQ r / .. - ---- ----- -- cENsus TRACT owner's Name... %ddress-------------- --- // , --•---- --- -------Phone /� -- ��--- city.....-,�_ _ ------ --------_._. Z��.T 3ontractor's Name. Y�t fc' _ p---------------------- `' ........................License #. . E . � nstollation will serve: l-. _Phone_ � ' Residence El Apartment Hausa rnercial ❑ Trailer Court ❑ ❑ Other..' ._ _ZA41 cf ' �fumber of living units:............ `� Number of bedrooms------------Garbage Grin der.__• __.--_Lot Size..._�yC �/, ` later Suppfy: Public System and name...._.--"."--_" ------------ :haracter of soil to a depth of 3 feet: Sand ------ -------•--.Private'E]— k ❑ Silt❑ Clay ❑ Peat Hard an [_] Sandy Loam Clay Loam ❑ ❑ .� p Adobe ❑ Fill Material_•. --------!f Yes, type------------ ----- - 'lot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be lace JEW INSTALLATION: � P don reverse side.} � (No septic tank or seepage pit permitted if public sewer is available within 200 fee#,) 'ACKAGE TREATMENT E ) SEPTIC TANK ( ) 'Size....Sixe--------- ------ ----- ........... ................... -Liquid Depth -----. Capacity.--- ---- -- ........Type ---------------------Material ------------------No. _ Compartments --- --istance to nearest. Well----------- ------ -----•------ Foundation-------------------------- --"-_-- ��' _..._. Materia. - Prop.p nEACHING LINE No. of Lines. L -- ....... ength of each line- Total Length = --' Bo `� eterTypF """"_- ` epth Filter Ntaferidl�- -� �•'�.~-_ istance to nearest: Well__...._.._ ,–`�'""� ___-. ----- ---- ..Foundation- -------------------------Property Line.-. ------- EEPAGE PIT ) ] Depth- .---- --Diameter----- ----- Number -------- Rock Filled Yes ❑ No .............. Water Table Depth...._.... { .......................................... .....Rock Size........--:............. Distance to nearest: Well..__..-.-'----.----` ..--...._-.".._...._.... .EPAIR/ADDITION (Prev. Sanitation Permit#.._ -----Foundation -------- ------ Prop, Line-------_---------- -eptic rank (Specify Requirements)-- ate------ - ---- ----- ----- ---- ---1 - k� disposal Field {Specify Requirements). , Ca r Y. ...... ............. + ------ ..... •. (Draw existing and required addition on reverse side) ---------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County lydinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Rome owner or licensed agents ignature certifies the following: i certify that in.-the performance of the work for which this permit is issued, I shall not employ an t o become subject�tp7Wo�k tr's Compensation lows of California." p Y Y person in such manner as i .. . 3y..---- ...:_....; •..•--....... ...............Title_...[ 1/ t4.."...L -1� ,. (I other than owner) - - � `= FOR DEPARTMENT USE ONLY f %PPLICATION ACCEPTED BY____.__.__. " - ]IVISION OF LAND NUMBER.-..... ---------- ------ ------- ---- - ----._DATE. - -�c? 7 ? _____________ _ ------ _ F IONAL COMMENTS ....... ----DATE.-- .....- -------- ------ ------ --------------- ------- - --------------- - . .... - i -.._ ... --- ----------•----....--------- , =ina! Inspection b by ---`-- ------------------------------------ """-"" -`""- - _ ,fi 13 24 Date. SAN JOAQUIN LOCAL HEALTH DISTRICT- F65 21677 REV, 7/76 3M