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FOR OFFICE USE: APPLICATION FOR SANITATION RIERMIT t_ %f_.7/R? _ ;` (Complete Triplicate) Permit No. o� ete in Tri (Gn-r --- - - =-----------9�its �q �5`_. P � _______ This Permit Expires 1 Year From Date Issued Date Issued _-__ ! Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein + described. This application is made in/compliance with Cou ty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION --------` ! ""/� ------- - CENSUS TRACT Owner's Name __ ,__ -- ------------------ Phone) . yL..... Address ------------- --' Cit - --------------------- [�� - -------------------------- Contractols Name ----___--- -- s�-4O-------------------License # _/+ /� -- Phone5±_�-_ a. .i Installation lwill serve: Residence ❑ Apartment se'❑ Commercial:❑Trailer Court ;E] Motel Other --------------- --------- -------------- Number of living units:--_--1�-__ Number of bedrooms __-_! -- _ arba Grine Lot Size _r ___X_4 _______________ Jf Water Supply: Public System and name ---------- - ---------------------------Private ❑ Character]of soil to a depth of 3 feet: Sand I-] Silt CJ Clay ❑ Peat❑ Sandy Loam ❑ _ Clay Loam ❑ Hardpan ❑ Adobe Fill Material ------------ If yes,type ____________________________ (Plot plan, showing-size of I�ot,�locatiori of sysfiem in relation to wells, buildings, etc. must be placed on reverse side) NEW INSTALLATION: " ''�` (No septic tarik or seepage pit permitted`if:public sewer is available within 200 feet,} PACKAGE,TREATMENT [ ] SEPTIC.TANI(f ] Size_____ ______ ________ _______-_________-__ Liquid Depth -------------------------- i c Capacity ---------I--------- Type = ------ Material:_ M --'`s=---------- No. Compartments ------ ---• -• Gt S onf Distance to nearest: Well ----------------------------- _FooLindatio---------------------- Prop. Line --------- ,...... LEACHING LINE [ ] No. of Lines ________________________ Length..of-each line._•________________..______ Total Length _______-__-_________._..._- F 'D' Box-__�___:__ Type Filter Material :__-_____- yp -------------------Depth Filter Material --------------------•-------------------- ~y ODistance to nearest: Well __________________ __ Foundation _______-______________- Property Line ______--_______-_-_-__- ` SEEPAGE PIT [ ] Depth ______________ _____ Diameter ______________ Number ---_-______.______________ Rock Filled Yes [] No C] Water Table Depth ---------------------------------- Rock Size ------------------------------' Distance to nearest: Well.-,-V--------------------------------------Foundation :------------_------ Prop. Line ---------------------- . i _ REPAIR/ADDITION(PrevISanitation Permit# ------5______________________ l ---------- Date ____________ -------------------I Septic Tank (Specify Requirements) -------- -----------------=--------------- ------ - ----- ' �, r Disposal Field (Specify Requirement 1 -- _-- Q? h�r ____ --------------------------------------------- ------- -- -------------- --- --- -------- -- ----- '-------------------------------------------------------------------------------'----------------------------------- { - -- — - -- (Draw existing and required addition on reverse.side) I hereby certify that I have prepared.this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: i I3 "I certify That in the performance of the work for which thi's permit is issued, I shall notemploy any person in such manner as to become subject to Workman's Compensation laws of California." ' Signed -------- ------------ - ------- Owner BY r ---- ------------------------- Title ---------of th wner] FOR-Df�ARTMENT USE ONLY APPLICATION ACCEPTED BY ---G,r