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FOR OFFICE USE: +y: � APPLICATION FOR SANITATION PERMIT Permit No. ---- ------------------------- ------ --"--- ------------------------------------------ -- ------ (Complete in Duplicate) Date Issued ......................____._.._.---.-.------------- -. This Permit Expires 1 Year From 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 QQCoouunty Or nce No,,549. JOB ADDRESS AND LOCATION-____.Ill__!__-!__~,__________ _ _____________ _ Owner's Name--------- V - --- - -"------------- ---' ------------ - Phone__v�.'S_'_6Z-g� I r~t.Q.� Address--------------------------- ------ .-------------------------------------------•---------------/ Contractor's Name I ----------------------------- - Phone.7�!t-- / Installation will server Residence [[Apartment House ❑ Commercial ❑ Trailer Qati 1 2' Motel ❑ Other ❑ Number of living units: -,cP- Number of bedrooms -a;-_ Number of baths -v7-- Lot size -------------------- u Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Sic ft. Character of soil to a depthiof 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe P-11nardpan ❑ Previous Application Made: fllf yes,date----------- --------) No ❑ New Construction: Yes ❑ No D-**1FHA/VA: Yes ❑ No ❑ \` \ TYPE OF INSTALLATION AND SPECIFICATIONS: ' Septic SPECIFICATIONS- (No tic tankst r cesspool permitted if public sewer is available within 200 feet.) ( P , p °from nearest well��-Distan e from foundation.A1�_._._._._.Mate�al No. of com artments_ - Sized/� K-•S Li uid de th.-.__ Ca acit O4 P q P. -------"---- P Y l� Dispo Field: Distance from nearest well'___.'_....._Distance from foundation-_c�ef.__._..Distance to nearest lot line----5-____-- Number,of lines-------------Z----------- -------Length of each line___-�--------------"--.Width of trench...... ------------------ Type of filter materialz�xr_ _-Depth of filter material____' !_.--.--._Total length_-_.___-Sfax_____________________._ Seepage Pit- Distance to nearest well.___.-------------Distance from u m fondation_-. ( `_____..Distance to nearest lot iine---..5__1------ Number;of pits-----/----- ----------Lining material __.Size: Diameter._..37 ''.-.-.--_Depth-5 --------------------- • �s4 �' ai esspool: 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�o� -------------------------------------------- . , : ..� ------- --- -------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------- -----"- -- I hereby certify that I have prepared this application and that the.work will be done in accordance with San Joaquin County ordinances,Ifate laws, and rul9p and regulations of the`Sa oaquin Local Health District. (Signed) ------------ ----- - --- ---- ------------------"-"-----------------Pced -(O per and/or Contractorl g (Tale - ----------------- Y:---------------------•---------------------- ---------- ------------ --- --- ---- --------------------------------------- i -- .... (Plot plan, showing size of lot, location of system in r'elati to wells, buildings, etc., can bereverse side). FOR DEPARTMENT USE ONLY �y APPLICATION ACCEPTED!'BY---- ------ ' ___x --- -----------=--------------- DATE-----' r_!_.l. = ---------------- -- REVIEWEDBY '' `�- ----- --------- -------------=--- DATE------------------------------------------------------------- BUILDING PERMIT ISSUED---------------------------------------- --------- - - DATE--------------------------------"-"------------------------- - Alterations and/or recommendations:--- ! �� . ` N -----"--------"-------"------------------------------------------- -----•------ -------------- = -- a ------------- --------------------I------- '--------------------. ...... ------ ---"----------------------------------------- ----------------- --------------" -------------------------- - I FINAL INSPECTION BY:.....-- -`__ _!