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FOR nFFICE USE: FOR OFFICE USEt .... ......... APPLICATION FOR SANITATION PERMIT ..:....... (Complete In Triplicate) Permit No. .................. .%....�..•1: C. This Permit Expires I Year From Date Issued Dote Issued ..d.:... ..:....1 j PPlicatiin is hereby made to •::e San ;ooquin Local Health District for a permit to construct and install work herein described. 'is app!:-ation is made in .,mplionce with County Ordinance No. 549 and existing Rules and Regulationst OB ADDRWZ/I/CCyA.TION ! I �r L .�Lcre, ,. .. ,e••N7 /Q,CENSUS TRACT............ ..... .. twner's Name ./.�/ ,p YP-�-' __.. ... . . ._......... .... ... . ..Phone . ............... .... .. . .ddress .__. .7�2 �c�N'L.-�..e C-f"- .. CIty.. 'i.. .�!w!�.. ...... _ZI p............ ..... .. ... utallation will serve: . . J bntractor's Name. 50: _. .license /P. ......... ........ . Phone..................._... . ..... i .. Residence ❑ Apartment House ❑ Commercial ❑ Troller Court ❑ Motel ❑ Other . . _.. !umber of living units: . . ...... Number of bedrooms Garbage Grindrr............Lot Size....... .. .. .. . . . !oter Supply: Public System and name ............ .... ......._._.....Private ❑ haracter of soil to a depth of 3 feet: SunilSilt ❑ clay❑ Peat[I Sandy Loam❑ Clay Loam❑ Hardpan ❑ Adobe ;] Fill Material If yes, type.... ... ... .... .. . 'lot plan, showing size of lot, locution of system in relation to wells, buildings,etc.must be ploc•d on reverse side.) Z EW INSTALLATION: (No septic funk or seepage pit permitted if public sewer is available within 200 feet,) \ ACKAGE TREATMENT ( J SEPTIC TANK I I Size .. .. Liquid Depth ...._.... . .__ _�` Capacity Type .. .. . Material ....... ..... .... .....No. Compartments ...... . ... .. Distance to nearest: Well ...... . .....Foundation...... Prop. Line........ . . .. 'ACHING LINE I J No. of Lines ..alength of each line.... . .. ... ........._ . Total length 'D' Box Type Filter Material Depth Filter Material.. .. . _......... ..... ............. . ._ ._... Distance to neurest: Well . . ... . Foundation.... ................... Property Line .......... . _... °EPAGE PIT J ] Depth Diameter Number .............. ............ Rock Filled Yes❑ No❑ Water Table Depth _. . . ......-..Rack Size.. .. . .......L..... . t Distance to neoreo Well ....Foundation.. Prop. Line EPAIR/ADDITION (Prev. Sanitation Permit k .....Date . .. .. .) '-ptic Tank (Specify Requirements) tspssal Field (Specify Requiiemenisl ✓✓✓ - - _. . .. ............. .... .... .... ID,uw 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 Son Joaquin County rdinanees, Stale Laws, and Rules and Regulations of the San Joaquin local Health District, Home owner or licensed agents gnature certifies the following: certify that in the performance of the work for which this permit is Issued, 1 shall net employ any person In such manner as becorsta�' ,�ecl to %korkman'c/Aempenso!ion laws of California." gned `-•jsflr<'/!�-t:.t� G.v-f`a..�� Owner y .. Title .. .. . .. . .. (if other than owner) FOR DEPARTMENT USE ONLY PPLICATION ACCEPTED BY � � f/ �"- - - _ —_ .. _.... DATE �'.'•��- IVISION OF LAND NUMBER .. . . - DATE - DDITIONAL COMMENTS .. - -- - /. nut Inspection by. Date Sr.•1 JOAQUIN LOCAL HEALTH DISTRICT EYHIBIT A of 2 f