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TOR OFFICE USE: ----- ----------- --------------------------& APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. This Permit Expires ] Year From Date Issued Date Issued 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: JOB ADDRESS/LO ION ._,/ --------CENSUS TRACT -------------------------- Owner's Name { /`�* i � .�- �R ----------------------- --------- ----------------------- Address Phone JW A ` r Address / - - -- -- --- -- --- -- - - ------------------•------ -------------••---- 4 Contractor's Name _ , --�----,__-----License # 2f'Alll_____ Phoney � Installation will serve: Residence 4partment House[] Commercial:❑Trailer Court ;❑ Motel [I Other -------------------------- --------- ------- , Number of living units:____ ----- - Number of bedrooms _::_r------Garbage Grinder ------------ Lot Size -1440-1----- ---- ------ Water Supply.Supply: Public System and name _______________________ ----------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adob)K 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) k PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth -------------•------------ Capacity --- Type -------------------- Material---------------------- No. Compartments ----------------------- V'Distance to to nearest: Well ___;____ _____ �- - ---- -----------------Foundafiion -------- ----------- Prop. Line --------------- LEACHING LINE LINE [ ] No, of Lines r1 -- ----------- Length of each line-------------------- Total Length •-------------------- 'D' Box ------------ Type Filter Material ___________________Depth Filter,Material _____________-.-_ Distance to nearest: Well ________________________ Foundation -----------I_____-I-Y Property Line ---_________-----_ SEEPAGE PIT [ ] Depth _________ ________ Diameter ---------------- Number ----------------------- ---- Rock Filled Yes © No i❑ Water Table Depth ------------------------------------------------Rock Size ------------------------ Distance to nearest: Well ---------------------------------- ----Foundation -------------------- Prop. Line ---------------------- ' REPAIR/ADDITION(Prev. Sanitation Permit# _-______.________ __-_-________--.Date __________________ Septic Tank (Specify Requirements) ------ ------------------- ------ ----------- -• ------ ! - Disposal Field (Specify Requirements) - e ---- r------------ --- ------------------------------------- ` - - (Draw existing andrequired additiononreverseside} ------------------------- 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 "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 become subject to Workman's Compensation laws of California." Signed --------------------------------------------------- ------ Owner 4 By ------------- -----------------------------`--------------------- Title ----------------- -------------------- (If other than owner) ? FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 'BUILD DATE __ _'3�-_'�__ ------ ------------------------------------------------------- -- ------------------ ADD ING PERMIT ISSUED .._ __. --___DATE ----------------------------------------------------- ------------------------------------- ITIONAL COMMENTS --- -- --------------- --------�--`----- ------ - ----------------------------------------- --------------- --------------- -------------------------- -- ------- ------------------ -------------------- -------------------------------------------- --- - ----- ------------------------------------------------------------------------------------------- ------ -----------------•- Final Inspection by: ---------____ -----Date ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M