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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. . ................... ...... .......................... fL ' __.. 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 egulations:JOB ADDRESS/LOC A. G_ .._. . _. .. r .. .... .. ....... CENSUS TRACT -__------------ •--•-. FOwnerfs..,Nome ......:fi ... .. ....--- ` : c Phone . Address :; --------- -- A" .... C�3' ------------- -'City + Contractor's Name .. . �.V License # . 01,/. 7'Phone !, _ ' Installation will serve: Residence Apartment House❑ Commercial OTrailer Court ❑ N. Motel ❑ Other ....... .................... r �.... N tuber of living units:.. .f.. Number of 4erooms .. .__.._Garbo Grinder ."' ""lot Size ..... �.X.,� Water Supply: Public System and name . .:.- .. C� ----- -----.Private ❑ Character of soil to a depth of 3 feet: Sand Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay loam 0 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: fNo septic tank or seepage pit permitted if public sewer'is available within 200 feet,) PACKAGE TREATMENT [ 3 SEPTIC TANK'[ W6 11, f �---------------- - - •. ....... Liquid Depth .-.............. Capacity . Type -- -- ------ Material..-- ...... No. Compartments ---------------------- Distance to nearest: Well ...._.......................Foundation _. -- -------........- Prop. line ----------- ......... LEACHING LINE ( No, of Lines Length of each line g r` .��.....,:. :... Tato) Length 1�----.............. 'D' Box .-:`��. Type Filter Material _ -..._Depth, Filter Material Distance to nearest: Well -Gzf4i... Foundation lfd_...:........ Property Line _______________ 1 SEEPAGE PIT ° Depth � r ��._ ... Diameter _..�.�.. Number ............ Rock Filled Yes No C� .....Rock Size -. �. r Water Table Depth /-r-�- --------- ------- ----• ---•----- Distance to nearest: Well --------Foundation /.-.- Prop. Line .. ._.............. REPAIR/ADDITION(Prey. Sanitation Permit# _._.__ ... ...... ..................... Date ....._....-----------.:_______..__] Septic Tank (Specify Requirements) . . --------- ------------------- . ------ ........ e -_. ... ..... ......... 0 Disposal Field (Specify Requiremen ) -_-- - -_----- rte..---- s .. ......... .. .... ....... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work Will Ibt done in accordance with Son 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 certify that in the performance of the work for which this permit is issued, I shall net employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .... ..... ......... Owner By Title ........:.... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... . .... -yam} - DATE .. -4 ._..�...............__.._ BUILDING PERMIT ISSUED - ---------------- --- DATE . ADDITIONAL COMMENTS ................. . ........................ - --.. ^—� Fina Inspection by: .. ---------Z ---_---_ -------- ------ -------Date ----- . .-��b SAN JOAQUIN LOCAL HEALTH DISTRICT 13 24 E. H. 241.'68 Rev. SM _71j2.3 24. ,