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YFC'}R OFFICE= USE: } PLICATION FOR SANIYATiON PERJ (Complete in Triplicate) - - Dote Iss_Intl ..... This Permit Expires i Year From Date Issued .t ' n Application is hereby made to the San Joaquin Local Health District for a permit to construct and install :+he kvork herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: . y JOB ADDRESS/LOCATION '71a "'Y G� " I---.-..-CENSUS TRACT Owner's Name .. -` ------ ------- . -F -----.Phone Gr-C�.0�2. _ ____ _____________ r...3 �...:. ,� SLC City - Address + - z — f Contractor's Name } '. :,............. .:f � a.. - z fir.-,r:.License Phone Installation will serve: Residence ( partment House[] Commercial ❑Trailer Court 0 Motel ❑Other -------------- ------ Number of living units:...... Number of bedrooms ._----Garbage Grinder ............. Lot Size -------------------------------- ---------- Water Supply: Public System and name ------------- - --- ----- ---------- - --_--------------------- ------------ ------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt E] Clay ❑ Peat❑ Sandy Loam E] C1ay Loam E]Hardpan 1/ 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 f I SEPTIC TANK T ] Size-------------------------------- Liquid Depth ---_-..---------.-_----- Capacity .................... Type ------- - - ........ Material__ ........ No. Compartments ----- •- ------------- \ Distance to nearest: Well -----------------------------------.Foundation ---------------------- Prop. Line ----------._-_-._. LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-----.--.----..----.- ------ Total Length ---.-------------------.---- 'D' Box ---------- Type Filter Material --------------------Depth Filter Material -----.......-------.---.----------.-- ---.- Distance to nearest: Well ------------------------ Foundation ..__.-..-.- -- Property Line ---------._.-._-__.-_-__ SEEPAGE PIT [ ] Depth .................... Diameter ---------------- Number -- ----------------- Rock Filled Yes ❑ No C3 Water Table Depth ---------- -------------------------------------Rock Size ----------------------. Distance to nearest: Well ---------------------------------------Foundation --.----------------- Prop. Line ..--------------.--_.. REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------- ----- Date ---.----.---.-------------------.-} Septic Tank ISpecify Requirements) ........._ ------------- - ------ ------------------------ ---------------------I—— R Disposal Field (Specify Requirements) --------------- - - ------------------------ ----- ---- --------------------------------- e ---x4= -'- / r -- --------- J (Draw existing and required addition an 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 Sari ,Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California," Signed ... ... .. ------ --- ---- ------------------------ -- -- Gruner Title ._... ........ !Ir' other than owner) FOR DEPARTMENT USE ONLY ,aPP! CATION ACCEPTED 8 '[�/ _.... _ DATE ..... ..Ic1-_.........--- •-,. ;L'!LDII :� PFnJr,;;. €:.�t;F: DATE - - -- ------ -------- ----- -------- - --- --------_-----