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FOR OFFICE USE: 4-5 APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Permit No. _4 S _7_ / Date issued-ld=-_�/'C(•� ------------------------ 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 madelin compliance with County Ordinance No. 549 and existing Rules and Regulations: ee - - ---CENSUS TRACT --------------- -•------ - JOB ADDRESS/LOCATION _---�d4------ -16-IL------ r--------- -------------- --Phone------------------- Owners Nameiwllllwa. r1'`J--------- Address -------------------------/-�---- 8-� -s--------4�.� � ��-------------------------- city �Jfu� �'+ 1` t Contractor's Name --------- /=� tl—VA§oo----- � �' d�----------------License # �`yjq _ Phone X %� ` - I. Installation will serve: Residence [Apartment House❑ Commercial :❑Trailer Court ❑ Motel ❑ Other-------------------------------------------- Number ------------------------------------------ Number of living units:--..------- Number of bedrooms _2 ---Garbage Grinder ------------ Lot Size - I• • Water Supply: Public System and name-----1�%�li _ Tit _. �----&--------------------------------------- ---------Private [_1 t Character of soil to a depth of 3 feet. Sand'❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ f Hardpan ❑ Adobe 12' 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.) NEIN INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) SEPTIC TANK: Size------ -0s2-�9----'3�t�------------ Liquide Depth ----4a----- PACKAGE TREATMENT M- - [ ® No. Com artments _---•.•---=- Capacity _� -��1- Type AWW—Tr- Material--------------- * i Distance to nearest: Well ........ __-�-~---•------- Foundation ----- / ----------- Prop. Line __13 _:------_„•- i LEACHING LINE [-f No. of Lines -._-_J-------------- Length of each line--- --- ---- - --- Total Length :--Gya ----- _ 'D' Box --- �_---- Type Filter Material ------DepthFilter Material------��------- } Foundation J ----- --- SEEPAGE PIT Depth _---- -------------------- - Property Line --�s._�--------------- Distance Distance to nearest: Well -_-------__-------` -------- Diameter .---------------- Number ------ Rock Filled Yes E] No i❑ [ ] -----, WaterTab� le Depth ------------------------------------------------Rock Size -------------------------------- ! ---------Foundation -------------------- Prop. Line -----•----- ---- = Distance to nearest: Well ------------------------------ � I-------- Date---------------------------------- REPAIR/ADDITION1 (Prev. Sanitation Permit #-------- ----------------- Septic Tank (Specify Requiremeits) ------------------- -: --------------------------------- Disposal Field (Specify Requirements) --------------- ------------------ - ----------------- ----- ------------------------------------------------------------------ - --------------�. ---------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ (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 licen- sed 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 j as to become subject to Workman's Compensation laws of California.” Sig ------- - ------ Owner - ---------- �__ -- Title -_ ------------------ -------------------------------------- (If other th owner) f FOR DEPARTMENT USE ONLY f 1, b APPLICATION ACCEPTED BY ------ ---- -----'�`------------�-------------- DATE -_�- / _----- BUILDING PERMIT ISSUED -.- DATE --_---__- - t ------------ _ �-----1s'e'� ----- ---- fit.,_. �-: ADDITIONAL COMMEN 7 �l� S ----------------------------- ,---- ------------------------------------- _/.PW�:�� r - --------------- ---------- -------------------------------------------------------------------------------- -- Date - 0------------ �. - Final Inspection Y: ----- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. -H".9 1-'68 Rev. 5M•