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FOR OFFICE USE: .� - ---- APPLICATION FOR SANITATION PERMIT Permit No. . . :?... _ - (Complete in Duplicate) Date Issued .. .. .................. This u licate This permit Expires 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 Ordinance No. 549. AJ; JOB ADDRESS AN LLOCATION �5- --_ __________ ___---------____ - .. .. . Owner's Name------------ n..�c.. --t� Phone............. +e -5 /Q Address------------------------ r - -----------••--- ..je-------- Contractor's Name------------------------------------------------------------------------------57 --- -----------------------•--------•--=------------------------------ Phone.........................------ Installation will serve: Residence Apartment H esuo Commercial E] Trailer Court ❑ Motel ❑/ Other F1 Number of living units: _j___ Number of bedrooms .--3- _ Number of baths _Z_ Lot size Water Supply: Public system ❑ Community system ❑ t'Private [g--Depth To Water Table , ft. M Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [-Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,dote__------------------) No []_---1Vew Construction: Yes ❑ No E1_--FHA/VA. Yes ❑ No E�-" TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) W Septic Tank: Distance from nearest well----- Distance from foundation----1�--------Material------ ...... [a/ No. of compartments_______-__ Size----% ,�_,�,[ --Liquid depth_________-.-�0--_._____Capacity-------- C;L_A---- Disposal Field: Distance from nearest well-----Z.e----Distance from foundation_-____- .....Distance to nearest lot line_... 3.-G... Number of lines------------------Z�----_-_.-.Length of each line------------- ------Width of trench._......_.______�___----.-- Type of filter materidl._ -___Depth of filter material------ length---------------- ____________ Seepage Pit: Distance to nearest well__ ________________Distance from foundation---.................Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter----.-----------.---_Depth----.---..--.-.--_------........ Cesspool: Distance from nearest well-----------,-.__Distance from foundation-------------------_Lining material-___.__--_--_______------...._-._.___ ❑ Size:-Diameter---------------------------------------Depth----=-----------------------------------------------Liquid Capacity---------------------------- Privy: Distance from nearest well---------------------------------------------.-.._Distance from nearest building------------------------------------------ 11 Distance to nearest-lot line----------------------------------------------------------------------------------------------------._....---------------••-------------------- Remodeling and/or repairing (describe):---- Q ------- _,...---- �r� -x r•.• •-.-... �] --- ------•----------••----------------------••--------------•-----•------------.......----•-••------------•--....._........ -------------•--•---------------------------------------------------------------------------------- ------------------------------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 regulations of the San Joaquin Local Health District. =.... gid. . (Signed)--- - ---- ------�--�'`�---------- --------------------------------------------------------- ------------------- -----{C ner.-and/or Contrac+orl.. By:--•------•--...--•-••--------------------------------------------------------------------- ----(Title)--------- (Plc+ 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 ACCEPTS© BY ''2-=�' �l ---2....--- DATE REVIEWEDBY--------------------------------------------------------------------------------------------------------------------------•-•• DATE-------- PERMITISSUED-----------------------------------------------•-----•---------------------------------------------- DATE------..--------------------------------------------•-------- Alterationsand/or recommend'ations: --------------------------------------------------••-----•------------------------•---••----••----•-----------••--------•------------------------••---- . - ------------------------- ------------------------------------------------....-------------------------------------------------- ------- FINALINSPECTION BY--------- ------------------•---------- ....... Date-------_--------------------- -----------------...------------------------••--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street