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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) 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 LOCATIO ________ ___ _ _ ---------- ---- ------- .5---------- Owner's Name--------------- ----- ----------------------------------- Phone _- - Contractor's Name................. ------��- - - -------------- Phone--------------------- = = - - - - ---------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Ej Number of living units: Number of bedroom - Number of baths � Lot size------------ mm..... ,_�_ •-,• Water Supply: Public system E] Community system ❑ Private EV"Oe r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Gay ❑ Adobe U/Hardpan ❑ (�,`'� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public'sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation:----------------------Material-_-............................................ No. of compartments----.---"'-.----------------Capacity-,-------------- Size- --------------Liquid depth--------------------------- Cesspool: Distance from nearest well_________--------Distance from foundation--------------------Lining material-------------------------------------- ❑ Size: Diameter- -----------------------------------Depth-------------------- ------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building Distance to nearest lot line_______________________ Seepag Pit: Distance to nearest ell_____ -D ______Distance from fo nd_ ation______ , ---..Distance to nearest lot lineNumber of pits________ _________ ,s ____-__--- __ ngmaera.._ JSize: Diameter__ --_ _ Depth-------- ------------------ Disposal Field: Distance from nearest well_________________Distance from foundation______--_____:___-_Distan a to nearest lot line---._______- ❑ Number of lines-----------------------------------Length of each line------------------------------Widfh of trench------------ -------_--- Type of filter material--------------------------Depth of filter material_____________-________ •;: odel.in and/ r repairing desc b l •-- ni-o-s --------------------------------- _----------------------------- 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. 0031By:--------------•---:-------•----- ---- = (Title) ---------------------(Owner and/or Contractor} A. --{Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY -•------------ --- -- -- - = DATE_ REVIEWED BY ------------------------ ---------- -----•------------------------------------------------------------- ----- -- ----------•-------- BUILD ------_-_-_-_------------------v----------------- = --- -_ DATEiNG PERMIT ISSUED--------------- --------------- -- --------- DATE-- - -=-------Alterafigns nd/or recommendations ------- ------ ----------------------------- ----------------------- •-------------------- ------------------------------------------ - PERMIT No-_ 1U--------------- ISSUED---- _--y -5 -------------(Date) FINAL INSPECTION BY----------- -----J- Date___--__ s -- �� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES--9-2M 9-50 W-1539 Sfockfon, California