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FOR OFFICE USE:' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----77 ---------- ..... Permit No/- -5 ' {Complete in Triplicate} '' Date Issueo"'-�-.'� .. This Permit Expires 1 Year From Date Issued ruct and install the 4 y 549- p~ xistin' R Application is hereby made ta.the Son Jo aquin"1oca1 HealthOi'strot549 andre it togo const and Regulations: Work herein described. This application is made in compliance,with County Ordinance N JOB ADDRESS/LOCATION....� i4.7 /17ll PN 4�. ..... .G A. . . --- CENSUS TRACT.............. Owner's Name.--- JTI.!,��/.:. .A.....7�. r1�./L/aCI.S.. .�'. . o-------•- - - - ..Cit .o^SGIJ_1�.�.... --� �-� ......ZiP-- �. - -- 6 . ...17? ....... Y Address... ._ ISLicense #. 533-...._Phone.. Contractor's Name ... 1� SP_`t1 S ...... ............ lnstallation will serve: Residence [t�Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other- ------ ----------- ------.----•----------- = Number of living units:.--.-1._------Number of bedrooms-.. --..Garbage Grinder------------Lot Size................ privafie Water Supply: Public System and name_..... ---------- ----------------------- .----- ...... -................... Character of soil to a depth of 3 feet: Sand El Silt ❑ yClay-❑ Peat ❑ Sandy Loam JK Clay Loam ❑ Hardpan ❑ J Adobe❑ Fill Material _ .If yes, type..-- -------------------------- F } � (Plot plan, showing size of lat,";location�of system in relation tb%weks, buildings, etc. must be placed on reverse side.] k f NEW INSTALLATION: (No septic talk or seepage pit permitted"if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] -... - Liquid Depth ... Size... Capacity....._ �-----.- ---TYPe------- -- .....Material..-....... .... No. Compartments 5 \ r Distance to nearest: Well------------------ - -- - - .. `foundation....-_.._. Prop. Line Distance Length .. - -- ��--- •-..Length of each line.-- --'=-�--•-�-- ----- --- --- 9 ---------- --- ----- ......------ LEACHING LINE [ ] No. of Lines .; -.. . - 'D' Box.... .Type Filter Material.- :... {..Depth Filter Material... :.. l c ,' Pro ert Line---------- ------ - -------- i_:- Foundation- -.�-'---------•----- _ .._Ps y Distance to nearest: Well------------------ No ❑ -Rock Filled Yes ❑ SEEPAGE PIT ' [ ] Depth---- ...... Diameter.--=- ----------Number_:.:=:= Water Table Depth---------- - - '.;...-. .:Rock Size -:.... - _F ..Pro Line ---- ound ... .y. 4 Distance to nearest: Well--------------------- - .. ❑tion 5 ----- -- r ..... --) Date.'.. REPAIR/ADDITION .[Prev. Sanitation Permit#------ -------------- i i -------------- Septic Tank (Specify Requirements)- J ---� . ....... ... .................. i.. Disposal Field (Specify Requirements)._....-- ��Q �� `" i ------------ --- --- -- -- . ........................... , ............. (Draw existing and required addition on reverse side] ith Son uin County [ I hereby certify that I have prepared this application and that the work will be danepistrict Dome owner orJlic oaqnsed agents EOrdinances, State Laws, and Rules and Regulations of _the San Joaquin Local Health. signature certifies the following: erson in such manner as 1 "I certify that in the performance of the work for which this permit is issued,I shall not employ, any p ` to become ubject, t Workman's "Comp nsation laws of California." l� --------- - -.--Owner SigneBy - d �L�'- �- - . -- � -- ---- ... If other than owner) F R DE ARTME X U E ONLY -DATE APPLICATION ACCEPTED BY-.......... . ... ---... .._ --- - ....... .... . .... ..... . . ATE-_...... .. . .•- ----- - -- DIVISION OF LAND NUMBER � ® G,/ -- -- .... ._.. -- ADDITIONAL COMMENTS._ VC, ..w-------- -- t - .......... ........__.. .---"--.... .-- --- . �--- - .1-------------------- -- I " ------- .. . Date...' Final•Inspection b - --- -- _...- F&S 21677 REV. Z/yp 3� EH 13 24 ' S JOAQUIN LOCAL HEALTH DISTRICT 4