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FOR OFFICE USE; APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ------------------------------- (Complete in Triplicate) Permit No...17g-V I? --- --------------------- This Permit Expires 1 Year From Date Issued Date Issued___ _j 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: Y. JOB ADDRESS./LO �_ - '___ - -----7 ------ - ------------ - -- - - - -------CENSUS _ - TRACT---- i O-wr ner's-N-a.me ---------------- ------------------------- ------------------ Ir A ; y Ph e-- iP-ddress_.__ � _._ _ ." .-- ------ r) o- k _ ------------------------°City -- -- --- -- Contractor s Name---- cJ --`f q -- A ---- _ ----- License --------------Phone Installation.will'serve: Residences[ ;<Apartmerit.House❑ Commercial Ej Trailer Court ❑ N4ote ❑� ------- gunits: � i f ^sTT Garb""e.Grinder_._. e i r..�..:--• - .,. _ - - -- -------------------- Number of livor units:_____ .1____`_�Number-of. bedrooms=_._: ____ ` 9 _e_ . r " Water Supply: Public System and name-.____--_-- _ -- ; ---`. = --------Private I Character of soil to a depth of_3-feef:' S- and Silt ' . ❑ ❑ Clay ❑' Peat-©- Sandy Loam ❑ 'Clay Loam [1. + Hardpan ❑ Adobe'❑ Fill NMaterialf type�. �--•r yes, --------------- ------ ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, e'tc. must be'placed on reverse side.) { NEW INSTALLATION: (No"septic tank or seepage .pit permitted if public sewer is available within 200 feet) PACKAGE TREATMENT ["] , SEPTIC TANK [� ' - - ' Size_ /Q .''�`, i iquid Depth ,Y „ Ca acit - �o Q �• r Opacity =--- -- -,---,,Type -- Materialcrv�- -._ ._No. Compartments_.: _ --- ----'- Distance to nearest:.%Nell. .___5'a -� Foundation �` - •ProPi. Line-_15-4v '--- t LEACHING LINE [ No.-.of Lines -_-_ , __-- Len th.of each line. =_. 7t Total Len th __ G?_ _ 9 g - Distance to nearest:Type Filter Mat1rial-------, _R4_ Depth Filter M' r P Material /-17- -., ---- Stcm a est. Well .__ �±_4__ Foundation_. )_� �. - $ 5e A.!` SEEP,AGE`PfT T .. r _. .._ .�. :: :: t ....a.-, r [ , " --Property Line -. [ Depth 1-?--� 13Fer a Number = ; Filled Yes { Rock R r NO Water Table Depth - -0-6 {�----1- -----------------------Rock Size =-------- Distance to nearest: Well ` _.__(_Sa, .i'-------------------FouridationGLa' Prop. Line_ - 2.�f '""_" ----P a REPAIR/ADDITION(Prev. Sanitation Permit#__,•_______________._ -------- -- _ ___pate.____.__-_.___ ___ oc Septic Tank (Specify Requirements)--_____________ ------- F - ----- - Disposal Field (Specify Requirements) ______ _______ __. ----- ------ --- -- ------------------------ _ .: :- ----------- - - - -=------=-------------------------------------------------- t {Draw existing and required pddition7 reverse side) - . - .s . " ` x� I hereby certify that'l have prepared this application,and that the work will be done in accordance- with San Joaquin LLCounty Ordinances, State Laws, and Rules and Regulations of the. San Joaquin Local Health District: Home owner or licensed agents Sig' certifies the following: "I certify that in the peHoi•mance of-the work"for which'this per is issued, I shall not employ any person in such mannerras to become- subject to. .Workman's CompenscitionJaws .of California.". s 1 - Signed_ i C / BY ---------------- t t - -------- ------- ------ ner 1 Title. (I�f other than owner) Jr FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY___-- _ - -=- -DATE.._ _ _ _ _______--------------- DIVISION _ _ DIVISION OF LAND NUMBER. _ = . _ . - _---- ------:DATE_- - ' ADDITIONAL COMMENTS.__._:_ "..____ - = ---- ------------------- ------------------------- - - - - ----------------- t -- --------------------------------------- ----------- ---------- ---------------------------- ---------- ---------- Final Inspection by '- '= _.. _ t -------- --------------- EH 13 sa SAN JOAQUIN LOCAL 4EALTH DISTRICT y F&5 21677 REV 7/76 3