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FOR OFFICE USE: �: t r FOR OFFICE USE: APPLICATIOlak-1FOR SANITATION PERM \�'ti ..v.. R -3 \. \N_ (Complete in Tripfkate) Permit No..7a .. ---------------------- ------ ---- Date Issued--C=-d/-.-- This Permit expires T Year From DateIssued 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 r an o 49 nd isting Rules and Regulations: JOB ADDRESS/LOCAT 174-61- F/--- -- --- _------ ------ ---------------CENSUS TRACT----. ---x- -- ----= Owner's Name-- ---- -- ---- - .-- one h Address //�� SLI City ziP. ,✓ Contractor's Name-------;- _ - - - - .__. License #- hS'.3_ .Phone--- ---- Installation will serve: Residence Apartment He .❑ se ' Commercial C] Trailer Court ❑ Motel ❑ Other - ----- -- -- ----- i Number of living units:__. _____Number of bedrooms __Garbage Grinder.------------Lot Size__f-T�/:V410.te_3 ------------------- Water .-.-_- --_Water Supply: Public System and name------------------------------------------------------------- ---- -- - --- ------ -- - --- _--Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay fl Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe)jr 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 seepa a pit permitted if ublic sewer_is available within 200 feet,) _ CT PACKAGE TREATMENT ( J SEPTIC TANK ( Sid _> !cr ., __ _____ __ q p '�I__._.._._ ______Li uid Depth ___r Ca acit j/ P Yj 60-0-----TY �__-Material_ No, Compartments Distance to near t: Well--- 44------------------------Foundation.___--------_ ---Prop. Line__ 40----------------<-- r t ♦ I LEACHING LINE [l'No. of Lines-*-.2--------------------Length o ach line _ Total Length ___.__. _____________ it D' Box Type Filter Map - - fle terial_�i pth Filter Material------_, ------------------------------------------------- -Distance to nearest:4Ne1 ___ �_ Foundation__- * __.Pro Property Line-- Q _ice � *- P tY SEEPAGE'PIT (t,}� Depth �1_-___Qiameter_; Number__-: _______ ______ y Rock Filled .Yes No❑ Water Table Depth-- -----• - - ----Rock Size_ .. _ ---_- __--- Distance`to nearest: Well---*---off 4-----------------------_-foundation---- -G?---_--------Prop. Line_ --.___- ___._._;._.. REPAIR/ADDITION (Prev. Sanitation Permit#- ----------- ------------------------------ ate- -- ---- --------- -----.----------------- Septic ----._.----Septic Tank JSpecify-Requirements)--------------------------------------------------------------------------------------------------------------------------------------------------- = -- Disposal Field(Specify Requirements)---- -- -- - ............ --- -• ------ ----------------•-- - -- - -------- ----------------- -••-----•--•---------•--•----- ------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- - -----------_-•- -_--- ---- ----- --- ---- - ----- - ------- ----------- ~ (Draw existing and required addition on reverse- ide) 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to becom bject to Wo man's Compensation laws of California." Signed_.__ _` ------- ----- -- Owner BY- ----------------------------------- �'Sl _Title- ---- >r (If oanowner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -- --------- ------- ----- - - -------DATE J- -XI-19 ----------------------- DIVISION - -----------DIVISION OF LAND NUMBE ---- --------- ------------------------------------ ------------------------------------------ ------DATE---- ------- --=--- ------ ADDITIONAL COMMENTS- ----- --- -- ------•-- ----------- ---------- ---------- ------------ -------------------- ------ - --------- ------------------------------------------------------ ---------------------------- - g Final Inspection by• ---- - -Date----- 1-. 1 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677.REv-7/76 3M