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OR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. . CfS� ICompl*te in Triplicate) ."' "' """ This Permit Expires 1 Year From Date Issued Date Issued ................... icotion is hereby made to the Son Joaquin local Health District for a permit to construct and install the work herein ibed. This application is mode in compliance with County Ordinance No. 549 and existing Rules and Regulationst ADDRESS/LOCATION llj1.eL:�F_./_06F, .1114r-2y...�c�' ...CENSUS TRACT ................... per's Name '��.. ' ../��i'�F-.............. ............................................. . phone ess ��/9'4:7U:............ . ...................................... City /It'�i� .h................. ..........................._. actor's Nome ...... fir.,-�0�/.G/.'. .._.......... license#ZJ X. 5 ... Phone Z"-nZ Z:...... ................... illation will serve: Residence IgApartment House❑ Commercial❑Trailer Court ❑ Motel❑Other ........................................... .)er of living units:../..... Number of bedrooms .42....Garbage Grinder/!/..... lot Size /l(OZ', Nt................. r Supply: Public System and name ............................................... ......Private Qg otter of soil to a depth of 3 feet: Sand p Silt❑ Clay ❑ Peat❑ Sandy loom ❑ Clay loam❑ Hardpan❑ Adobex FIII Material ............ If yes,type...................... ..... plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) •INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feeta AGE TREATMENT ( ) SEPTIC TANK t J Size................................................ Liquid Depth .......................... Capacity _..... ............ Type .................... Material...................... No. Comportments .................» Distance to nearest: Well ....................................Foundation...................... Prop.line.................... p SING LINE ( j No. of lines . .......... ..... ..... Length of each line .......................... Total length .................. 'D' Box . ... . . Type Filter Material ....................Depth Filter Materia) ............................ ......... Distant.^ to nearest: Well ........................ Foundation ........................ Property line ....... ................ GE PIT ( ) Depth .. . . Diameter ................ Number ........................... Rock Filled Yee ❑ No ❑ Water Table Depth .........Rock Sire .................................... ................................ Distance to nearest: Well . .....................................Foundation .................... Prop. Lite ........._........ . F/ADDITION(Prev. Sanitation Permit# ........ . ................................. Date .................................) ,tic Tank (Specify Requirements) .. .......,.,................... ............. ....... . _................. oosal Field (Specify Requirements) 1 .........3�y�.1.r�..fiE%./fft.. !/J �r.....f� J«�......................... G•-!/�B [ �'/.J`' . . ................................................................................................................. .............. _.... ..... ................................................................................. (Draw existing and required addition on reverse side) oy certify that I have prepared this application and that the work will be done in accordance with San Joaquin Ordinances, State laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or Ikon► ents signature certifies the following: fy that in the performance of the work for which this permit Is issued, I shall net employ any person In such menner *come subject to Workman's Compensation laws of California." /� ... .. ... Owner l _ ... .... . ............... .......... (If r than owner) FOR DEP11TMENT USE ONLY A— ACCEPTED BY .%�.. ' .. . .. ..1. :r.l. .............................. DATE ...� . _ r... ...... 11 RMIT ISSUED .................... ....:...............................................................................DATE .......................................... ONALCOMMENTS ..............................................................................................................................................................