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APPLICATION FOR SANITATION PERMIT Permit No, (� (Complete in Duplicate) / Date Issuec! 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, JOB ADDRESS AND'LOCATION-------------2428_country club _-- ---------------------------------------------------------------------------------------- Owner's Name------'At--�-'-��@r--------•------ E ---------------------------------------------------------- --------------------- -------- -- - Phone----H•4.3--574+ --------- Address----------------Same f _ Contractor's Name-----I_�_f_S___SEPTICTANK-S ,527fi--------- ______ _ __ ____ _ __ I one.__ - Installation will serve: ResidencelM Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms _�___. Number of baths __1__ Lot size).QQK ___________________________________________ Water Supply: Public system ❑ Community system. ❑ =Private:K] Depth Ito Water Table _-1-5__ ft. Character of soil to a dep+h of 13 feet: Sand ❑ Gravel ❑ Sdhdy Loam ❑ Clay Loam ❑ Clay ❑ Adobi:S Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ , f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest we!}------- _ D1Msancergm ounaton___________ 0_ Cbric .•----------------- 54 -------=•-- 4 77 X40 Liquid1 ---------Capacity.- __800--$81No. of compartments-------_-2______-----_--Size---•------5 „ - � Disposal Field: Distance from nearest well____ --- Distance from foundation_ -___-t--_._. Distance to nearest lot Iine10__fts_-_ gl Number of lines---------------------- ------------Length of each line------4Q-4s--------.Width of trench-----2413i-.------------------ Sump Type of filter material___Rock------------Depth'of filter material----IZ ft`__Total length-------40ft-------______;_,________ Distance to nearest well____90f-t-_____Distance frm foundation____________________Distance to nearest lot line------10ftq.r :C] Number of pits-------- ------------Lining material--------- _ -------Size: Diameter-------4_-X._6-ftDepth..........6,ft---------------- Cesspool: ------- ------ ) Cesspool• Distance from nearest well-----------------Distancefrom foundation___ - %_ material__________________ __________________ 04 F1 Size: Diameter-------------------------,-----------Depth--_--------------- --------------- - -------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------------------------------------.-Distance from nearest building------------------------•----------------. ❑ Distance to nearest lot line------------------------------------ -----------------------r--- ------------•--------------------------------------------- -------- ti Remodeling and/or repairing {describe) g---------------------------------------------•------•--------------------------------••-----•-------•----------- --------------------------------------------------------------------=---------------------------------------------------------------------------- ----=----=--------------------------------------------------------- O ------------------------ --------------------------------=--------------------------------•-------------------:------------------------------------------------------------------------------------------------------------- .� I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San.J'oaquin Local Health District, (Signed)__-__-7/(*�____.i?7cf____-__� .n_ ______(Owner and/or Contractor) Bye..c� --------------------------------------------------------------------------------------------------------(Title)---------d-W- ItM'"_---------------------.---- - (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ ----- ------------- ----------------------------------------------•------•---------------- DATE---------------------- ' REVIEWED BY------------------------------------ ------------- --------------I ------ - ---- ------------------------- --------------- DATE---------------------- ..•..—------ ------ -- ------ BUILDINGPERMIT ISSUED-------------------------------------------- ----------------------------------- DATE------------------------------ --------------------------- Alterations and/or recommendations------------------------------- -- ------ ------------------------------------------------------------------------- /---------------••------------- ---------------------------------------------------•--------------•----------------- ----- - ------------------------------------------------------- --------------------------- .-- ------------------------------------------------------------------------------------ --------- ---------------------------------------------------------------------------------- - --------------------•-------------- ------------------------------------------ ----------------------------------------------------------------------•--- -----------------------------------•---------------------------------------------------------------------------------------------------•------- FINAL INSPECTION BY-------------- ----------------- ---------------- Date_ 1 41 �;_.%-------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 West Oak Street 132 Sycamore Street 814 North "C" S}tee+ Stockton, California Fadi, California Manteca, Californie Tracy, California ES-9-2M Revised 1.57 F.P.CO.