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. . FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (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/LOCATiO .... . CENSUS TRACT ....._-_ ------------ �.: ............ Name e .. pti�,..... or__- Phone �.... .. ...... Address Nam r A '" ..a' ..?f M.. City .,. at :1+ . . .° + .-r.....................- Contractor's Name # :. .. Phone ....- _---- ----. Installation will serve: Residence[3portmentHouse❑ Commercial ❑Trailer Court F) Number of living units: Numberofbedrooms ...-3.....Garbage Grinder . .. . .. lot Size .. r._:-'::•...:•.:N:_C?�-:_------. 4 ` Water Supply: Public System and name . . ....... .. ....... .. : ......... .y... ---Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay E3 Peat Sandy Loam ❑ Clay 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, s%werJs available within 200 feet,} PACKAGE TREATMENT [ I SEPTIC TANK I ] Size.---.- -.--•--:--•....:..... ...... . ... .... Liquid Depth -- _ ----....---..... Capacity Type .... -. Material-.-:-- No. Compartments '...................... . f Distance to nearest: Well .....::......'.Foundation . Prop. Line.--.--_--------.-...- LEACHING LINE [ j No. of Lines Length of each line Total length _-. 'D' Box _ Type Filter Material .... ......... Depth 'Filter Material ... . .......................... ......:-. Distance to nearest: Wel! :.._. _..._. Foundation _ . _ ._. Property Line ...........:. SEEPAGE PIT { j Depth _ Diameter _ _.--- Number Rock Filled Yes ❑ No t❑ Water Table Depth .- ------------Rock Size ........ ............ Distance to nearest: Well . ... ................ _-.-,_......Foundation ... ....., .. ....... Prop. Line ..........--........-. REPAIR/ADDITION(Prev. Sanitation Permit# .- -. Date _-.._- ------} Septic Tank (Specify Requirements) . Disposal Field (Specify Requirements) ..> ?_..., . ..Y. 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 Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or Niton- 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 . -- Owner ;d L e z' Byas :" . G... "` .r..a. r:° Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE . BUILDING PERMIT ISSUED DATE .. .... .... .... . ....... ADDITIONAL COMMENTS ........ - - - _ - -. . } e �3 _------------ Final Inspection by. . .... ...,,0r �.-..tom '..' -... . ................. _ .. .. .... Date - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 24 1-'69 Rev. SM 7/72 3 \1 n 4