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FOROFFIGf k•17 t � � ---. i ------ �---- _____-_-_ APPLICATION POR SANITATION PERMIT Permit No. ._ 5�- - �.._. - --- - (Complete in Duplicate) This Permit i-x ires 1 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 Ordinanc o. 549. JOB ADDRESS AND CATION.._!Y7" -------------•-------- wner's Name_. _ ---- ----•----••------•-----------------•------------------------------•-- ------ Phone---------------- Address..____. _ •-_------ -•- ----------------•--•••--_..Contractor's Name__________ v ---- -- •------------ Phone ------------------ Installation will serve: Residence Aparfinent House ❑ Comrtlercial ❑ Trailer Court ❑ Motel ❑ Other [) Number of living units: --I-_ Number of bedrooms %g--- Number of baths _/___ Lot size f Water Supply: Public system ❑ Community system W-F'rivate ❑ Depth ro Water Table t- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�dardpan ❑ Previous Application Made: (If yes,date____________________) No 59" New Construction: Yes 941"no ❑ FHA/VA: Yes gPo'No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) K Septic Tank: Distance from nearest well__________ Distance from foundation___ d 16� No. of com artments__"_ Size- -- ro - ,A'_Liquid depth--- ;or ! ��----- --------Capacity..��............ Disposal Field: Distance from nearer welt_____ ___-__Distance from foundation.__��_ Distance to nearest lot line___-_--• -- Number of lines___.._._ Length of each line_ ! -- - g ��._ -ss� --/Width of trench___-,�..-- �- Type of filter materlal� / ."-"•Depth of filter material-", �_""-•"-Total length_._,�o3_a Seepag Pit: Distance to nearest well_____ ----- -------Distance f fou dation_.___ _.._ -r. / �� _Distance to nearest lot line__>��.'"~•--_"•• Number of pifs.___ — Lining material_. _Size: Diameter__ .. .- Depth ----------- Cesspool: Distance from nearest well-----------------Distance from foundation-:-------------------Lining material-_--____--_ ❑ Size: Diameter------•------•------------------------Depth-------------- ------Liquid Capacity---------------------------gals. . Privy: Distance from nearest well--------------- --------------------------------- Distance from nearest building-------------------------------- """"_. - ❑ Distance to nearest lot line--_-_---______._____________ Remodeling and/or repairing (describe):_____-� --------------------------------------------- -------------•--•----"---- -------------- ----------• -----•-----•-•-------------I----------------------------------------------------- -------------------------"•------•--------•---.---"-•----------- --------------•------•------------ ---------------%------------•-•-- ----••---------•---------•--------------•-------------- -- 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 egulations of A San Joaquin Local Health District. (Signed)---------------- -- •-- or Contractor) BY- y {Title) �11 (Plot plan, showing size of lot, location of system in relatio wells buildings, etc., can be placed on reverse side). ; FOR DEP TMENT USE ONLY APPLICATION ACCEPTED BY_- ___ -" -"-___ 1 DATE_ --------------------------------------- ---- ------------------------ l0.. REVIEWED BY_.. .... ---- ----- ----- DATE BUILDING PERMIT ISSUED------_-__----"-- 7 ---------------•-•-