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APPLICATION FOR SANITATION PERMIT Permit No. s 5.� .-__--------- (Complete in Duplicate) Date Issued VV Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the SCA% . This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION .,`:------------------- ` --- ----------------------------------------------- Owner's Name__________________ './J� /I/� c r' ------ Phone------------------------------------ Address--------------------------------------------------------- Contractor's Name-------------------------------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 12 C-41/eleAl Number of living units:/_✓O" Number of bedrooms -------- Number of baths -------- Lot size ----- D✓'Y��Q_✓----- _ Water Supply: Public system ® Community system ❑ Private ❑ Depth to Water Table -------- ft. St Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ILA Previous Application Made: Yes ❑ No ® New Construction: Yes X No ❑ Q , TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) NonL C'�eYo Septic Tank: Distance from nearest well---- _Distance from foundation___.ld___-_--__.Mat dal_______________________________e-t''I�.____ � No. of compartments-_____-.1__--_-_.-__Size--- _! _ _X__ __-_._Liquid depth_..---_�_______-__.__Capacity.... '�_C`1____ Disposal Field: Distance from nearest well..____.--.....Distance from founclation.. .d _____.Distance to nearest lot line------ --- ...._.__ Rj Number of lines----------L--------___ ____ _ _ ____Length of each line------ ,0 Width of trench------ ------------------ , Type of filter material___ 464- -Depth of filter material__. /�_:-____-__Total length---------__�_�-_--_:_•_____________ � Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nea;est lot line._-_-_--_--__-.--� ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------------.---------Dept h-_______________-__._-_--__._- w 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 hereby certify that I have prepared this applicatfish and that the work will be done in accordance with San Joaquin County ordinances, State 1pvs, and rules and regulations of the San Joaquin Local Health District. in (Signed)------• ------ - ------------------------------------------(Owner and/or Contractor) By:------------------------_---------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT US ONLY APPLICATION ACCEPTED BY_----�. _.r_�f___ _ - =---- _- ------- DATE------ -------- -----... -- -=�--�---- -------- REVIEWEDBY---------------------- --------- ------- ------------------------------------------------------------------------------ DATE-------------------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE---------------------------- Alterations and/or recommendations:-----*-------`-----------: ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------- -------------------------------------- -------------------------------------------------------------------------------- ------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ,; FINAL INSPECTION BY:.. A -------------------------------- Date- - - _