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10 df USE: FOR OFFICE USE: FOR e PLICATION FOR SANITATION PERMIT I ................................. ...... ........ (Complete in, Triplicate) Permit .... ...).................. , ................. . :_. 1 Date Issues' -?7 t I ........................:................................ This Permit Expires 1 Year From Date Issued Application is hereby made to.the Son Joaquin Local Health District for a permit to construct and install the work herein described. This applicatioh is made in compliance with County;Ordinance No.t49 and existing Rules and Regulations 117 JOB ADDRESS/LOCATION.............I........ L ...CENSUS TRACT.................. ........... ........... ..4................... ..............*......... ...........*....... Owner's Name.-.. -.' `7....... ......... .....I............... 71 ...........................................................Phone... Address............... IW 14 .. T ..... .. . .... l. . ... .................................I... .... City. h /."y...... ..zip.....-.............,......-... Contractor's Name........ A-11..... 7 .C_....._....... ....I.. ........License Phone.0_675.!�� ..... Installation will serve: Residence Apartment House 0 Commercial 0 Trailer Court El Residences 0 Other....... A....................................... V52 /...... ...... .. . Z I I I Number of living units:.-]...........Number of beclrooms..:5.. '..Garbage Grinder.....,-.....Lot Size................ ................... . Water Supply: Public System and name.. ... ................................. ... ........:........ ......... . ...... ................. ....Private TA Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay 0 Peat 0 Sandy Loom 0 Clay loam I)p Hardpan E] Adobe El 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: JNo. septic tank or seepage pit permitted if public sewer I r is available within 200 feetJ PACKAGE TREATMENT 1,1 SEPTIC TANK [ I Size -5.......... .........Liquid Depth...:S.. ..... ......... Capacity. ........Typelow. rC Material...._.....................No. Compartments_.OR.......... .................I- . Distance to nearest; Well... .... ...... ..............Foundation. Prop. Line..._.._............. "? -r7- LEACHING LINE No. of Lines .1 .............I.......Length of each line A�V........ ..........Total Length ......... ................. 'D* Box- .......Type Filter Mqterial//,OX��epth Filter MateriaL..' V V .��.................. —- - ------- Distance,to npa[est: Well..,e�. .. ....... Foundat'lon..AA, ...........Property Line.... ..... ............. SEEPAGE PIT Depth... .... .....Diameter...:.................Number....r................. ...... Rock Filled Yes C] No Water Table Depth...:...........................:...................:.....Rock Size................................................ Distance to nearest; Well.- - o .........z....:................ .......Foundation................ .. ......Prop. Line....................... REPAIR/ADDITION (Prev. Sanitation Permit#.......... : . ...... , . ........... ......:...- ....Date............ ............ ......r.............. Septic Tank (Specify Requirements).... ....._...... . ...... ....................... ............................................... ....... .. . ....... ............. DisposalField (Specify Requirements) .......... ...... .................................................................. ......... ........................... ........... .......... ....................................................:............... ................... ................ --------- ------i..... . ....... ................... ......... ..... ..............."... ....r............I..................I——...........................................................:........ ................................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 San Joaquin County Ordinances, State Laws, and Rules and' Regulations of the San Joaquin Local,Health District. Home owner or licensed agents signature certifies the following: "I certify that in the perf9: rmance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject t 2W2�ojkmcin.s Compensation laws of California." Signed.......1 el .... .e ...........:....................... ....Owner By............................................................... ............ .................. ... ..... Title......................... ........ ........ .................... ...... . (if other than owner) FOR DEPARTMENT USE ONLY DATE ...... APPLICATION ACCEPTED BY..LL.<S ...............7........ ... . DIVISIONOF LAND NUMBER ..a�........1:.. ....q...... ...... ...........r............................. ...................1:_ DATE.......................... .... .. . ...... .. . ADDITIONAL COMMENTS........:.:.....:t.. .-.•:.........`,!:• .................... ... .. .................................... ............................ ........ ... ............................ ........r.............. ........... ............................................I...................................................................... .... ... .. ... .. ................................................... ..... .......................I................ ............................................................................................ ...... ...... .... ............. 7 .. ...... .. ................................ ...................... .... ........... ...L Final Inspection by:.................7L. . ... ... .... ......eul�. ... ....................................Date.. . .... ...... EH 13 24SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M re."',