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APPLICATION FOR SANITATION PERMIT rvlc vrr1%_C uZIc: ...----.--• ;"f X51 (Complete in Triplicate) Permit No............. -------- .......... ---- This Permit Expires 1 Year From Date IssuedDate Issued________ ___________ Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. Phis application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 1013 ADDRESS/LOCATION... ......... tr l"l..G_ ...................... ------•------ ----•- -----------.CENSUS TRACT---------- Owner's Name.--- .... . ©�y - - - -- •-- - - Address---a�!( �... �_ '�a4`� F`i1._._4k t �^ Ci '1�- zi Con#radar's°Name .......--..._......... License #. � _ ...Phone-- 5 - !/ !nstallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-..--------------••---•-_ = ff 'slumber of living units:...... ........Number of bedrooms.._,?.....Garbage Grinder.....___.__Lot Size...._---4 --- ..___ .......... Nater Supply: Public System and name_....---------___------------------------------ ---------------------------------Private -haracter of sail to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam [] Clay Loam ❑ Hardpan (W 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.) +IEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 3ACKAGE TREATMENT [ ] SEPTIC TANK '1r Sx ---------------------Liquid Depth.....:..................% Capacity-/ .......Type-= `i'��I...Material-- }��-�.---:._..:No. Compartments.--.-.:_-P_2.................... Distance to near_e. st: Well------- -_-:.____ . ►t._ _. ._ -a....c�Fo.undation--- ...... rap � _ .. _. Az EACHING.LINE j` ' No. of Lines -------Length of each ---- __ Total Length D' Box............Type Filter Material.;�t&/e_.Depth.Filter Material..-.._._/V.....___..._................................. - �t _ �...... � • _ _ -- - - -- - - -------- ..Property Line::.-------•..... ........... ,EEPAGE PIT C1}' Depth__'PZ.S..----Diameter----- -------.Number..------ ................... ' rr Rock Filled Yes ` No❑ ort Water Table Depth------ QQ---.......... ----------_------_--.Rock Size....011K-:----------_---_-........------ , -•---- -_.Foundation...�lQ.. 1-...... p.ProLine------- Distance to nearest: Well............ �.�_________._ . � -_-_ :EPAIR/ADDITION (Prev, Sanitation Permit#----------------------------------- .-- ---.....Date--.------.------ -...) ,eptic Tank (Specify Requirements)._-..-------------.___• - )isposal Field (Specify Requirements)--------------------- ------ )Draw existing and required addition on reverse side) hereby certify that 1 have prepared this application and that the work Will be done in accordance with San Joaquin County )rdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents ignature certifies the following: I certify that in the performance of the work for which this permit 6-issued, I shall not employ any person in such.manner as 3 bee*m /"blect to Workma Compensation laws of California.,' igned t•1-C- `�C --- __Owner ;y...... ,�Le��``-- - ----- ----- Title �.--------_--------- .. _ .. . (If other than owner) OR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY--------.-. -.DATE ..j0. e ? i )IVISION OF LAND NUMBER.--.......--------------------- i - ------------------ DATE kDDITIONAL COMMENTS-------_------------ ----- - -- --••-• ----------------- ------- ...................... ........................... -----------------• •---------- ---------------------------------- ..... ---•- ........... ............... ................... 4 --- - ----- --- -- f 'inal Inspection by:_.. = --••-•-•-•• -----------Date.-._ _'?b_ - I 1 13 24 CAU Ir%A(�I IIAI I r%rAJ WrA I TU MCTDIrT FbS 21671'06 27/76 3M 1