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--TOR-OFFICE USE: FAtI1t7U5t:: 'PLICATION FOR SA141TATION PERMIT .................................... .. . .......... t Permit No... (Complete. In,Triplicate), ........................................... Dote Issued.63.1........ ..................................... ................... This Permit Expires I Year From Date Issued oquin Local Health District for a permit to construct and install the work herein Application is hereby made to the SonJo" described. This application is made incompliopce with County Ordin(.;nce No. 549 and existing Rules and Regula ions- JOB ADDRESS/LOCATION........".e;.t. 7...... .7.3.9.... .....S- 11;!;ZrCENSUS TRACT.......................... Owner's Name ... ....�X xo s7— ---Phone.5.-? ...... ..............*..... ........ ......... .......**.............*............ Adclress..,5—.�P,L.T. . W. ........//....................... .......1............. .... ......I... ...� City... ....... .. .... ..zip--....:....................... Contractor's Name.......A e��1.i7ciz—4.6_�__40 ....license ��Phone....... ......................... . .................. ...... . ....._., Installation will serve: Residence?2 Apartment House 0 Commercial 0 Trailer Court El I Motel [J' Other...._.. ..................................... Z 4 C, Number of living units:....t.........Number of beclro6ims..3.. Garbage Grinder............Lot Size.......k� ........................... Water Supply: Public System and name.. .... . ...... Private ..r...... "I---- ----' 'I'll 11. . ........................... .......,.........................Private . ......*...... ....... Character of soil to a depth of 3 feet; Sand 0 Silt E) Clay 0 Peat E] Sandy Loam F1 Clay Loam 10* Hardpan 0 Adobe 0 Fill Material . .... ...-If yes, type.............................. . (Plot plan, showing size of lot, locatiorl of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTAL4ATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet, PACKAGE TREATMENT SEPTIC TANK [ I Size .. .... ...6- -s mOa . ...........Liquid Depth................... ....... Capacity./A�19........Type.. � Material..........................No. Compartments..,2...........................0 Distance to nearest: Well...... o=.7...........Foundation Prop. Line............ .............. LEACHING LINE No. of Lines ...............�_.Length of each i..Total Length ....... .......... ZA *D' Box.../.-- .-Type Filter Material..0>,,�/Wepth Filter Material.. .,.../.f... ......I............. ............. ....... Distance to nearest; Well./4--- ......... Foundation ; ...............Property Line... .................... SEEPAGE PIT Depth......... .....Diameter.-.:.' .!_ ....Number................................ Rock Filled Yes [-) No EJ�: Water Table Depth.............. T.._..........................Rock Size..... ........... .......................... .. t Distance to nearest: ........................ .........Foundation.........,...... .- ...,.Prop. Line...........................`" REPAIR/ADDITION (Prev. Sanitation PeIrmit#.......:.:.. ..........I... ...............Date.:.,... ............................... ...... Septic Tank (Specify Requirements)�__.'.. ..........I.........t............... ...................................... .... ..... .. .................................................. DisposalField (Specify Requirements) .... ........ ............. ...I...............................;.................... . .................................................. ....................................................... ................. .................................. ............................................... ................ ....................... 11 . . I ...........I....................................... ...................................................... .. ...................... ........ ........ ....................... (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 Son Joaquin Local Health District. Home owner or licensed 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 sub k ' Compensat. ject to or "n s ton laws of California." Signed...... ... ............................... ....Owner. By........................................................ ........ .................. .................... Title............... .................. ....... .. ......... ..... .... . . . (If other than owner) FOR DEPART ENT USE ONLY APPLICATION ACCEPTED BY........... ........... .DATE ................. DIVISION OF LAND NUMBER........... . ...... e.......... ................... ........................... DATE............................... ........... ADDITIONAL COMMENTS.. .................. ..... .. ......... .........I.......... .. .... .. .. .... ......................................... ..................................... ........................... .................................. ..................... ................................................................................................ ................................................... ................................Z........................................................................................ ...... ....................... ..... ........ ..... ... . . ...... ....................................................... ...... .........�t........... ............................... Final Inspecieon by:......................... ... Date EM 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M (LO-