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FUk UFFICE USE: 1PPLICATION FOR SANITATION PEI' 'T (Complete in Triplicate) Permit No. -........ .- 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS LOCA? N Q / Q . .. - ......CENSUS TRACT .._......... �. . , ._� [- . � _t', ._..._ .. Phone . .. ...Owners . _ . Addr . f� City . ...yl _ --- --- Contractor's Name # Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;(❑ Motel El Other Number of living units:.... Number of bedrooms -._ ......Garbage Grinder Lot Size Water Supply: Public System and name ------------ -------------...Private Lf7 Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy LoamClay Loam ❑ Hardpan ❑ 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.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-... ........_-........ _ . Liquid Depth Capacity - ..... Type -- ------------- Material.- ------ ------------ No. Compartments r................ ° Distance to nearest: Well .... ............ ......... ....Foundation . ....... .._.... ---- Prop. Line -------.--.----.---.- LEACHING LINE [ ] Nc. of Lines ... .. ---- Length of each line........ -- _. - Total Length - ----------. 'D' Box . . . Type Filter Material -- -- ------ ---Depth Filter Material . ..... .......- ..-... ...I—........... D-stance to nearest: Well . ... . . ........... Foundation - Property Line ............... SEEPAGE PIT [ ) Depth Diameter .--........ Number ............................ Rock Filled Yes ❑ No Water Table Depth -- --- - - .......Rock Size .. ..... ... . . . . Distance to nearest: Well ................. . .. .................Foundation ... Prop. Line __..._._-.__.._.__._ REPAIR/ADDITION IPrev. Sanitation Permit#-- -------- ----- -.._...----------------- . Date ---____.-------------------] Septic Tank (Specify Requirements) Disposc0 Field (Specify RequiCements) ........ .............. --------- . - . . -- ... {Draw existing and required additi n 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 fohowing: "I certify that in the performance av' the work for which this permit is issued, I shall not employ any person in such manner as to becom s b,ect to Workman's Compensation laws of California." Owner By Off others#iar7 ow ` " lam _ L, y{„1.�- G. o c Title t_c ;�-c." �� ) �- FOl? DEPARTMENT USE ONI Y f� _ iuQ.TIO A.CC r 1 F[1 BY e DATE !._=y.... f- i.D1NG P-L: ISSUED ............... .DATE ............. ... . I D'__',Il 10 1- COWA _ - ... - - - . . ......... . ......... .......... ... ... .._...... _.. --.. ...._.......... .. .._ ...... -- - - - - - .. .... ....... - .. _. ... .. . ... ..... . ....... ... .... - . . :Ali JOAC LIMN LOCAL HEALTH iDISTRICI-