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APPLICATION FOR SANITATION PERMIT Permit N.;? (Complete in Duplicate) J 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. Ii q JOB ADDRESS AND OCATI N --0-/ --- � --------------------------------------------------------------------------------------- - i Phone------------------------------------ Owner's Name-----• Address-------------------------=•-------—---------------------------------- --------• ---------------- -- ------------------•---- Contractor's Name-------------•-'1-----------------------------------------------`---------------------------------------------------------------------------- Phone-----------•---------------•------ ,i Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___-- Number of bedrooms __-. Number of baths I___ Lot size ------ OX l47�;?_-_____ Water Supply: Public system Community system ❑ Private ❑ Depth to Water TableZ4--- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ElSandy Loam ❑ Clay Loam F] Clay E] Adobe Hardpan'❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) [�� Septic Tank: Dotan = ,, rom nearest well________________Distance from foundation_________________---Malarial______________.___________________-________----. W 1N�" mpartments--------------------------Size--------------------------------Liquid depth--------- ---------------Capacity----------------------- 1 r xo , Disposal Field: Distance from nearest well 'E_._Distance from foundation_s__________________Distance to nearest lot line_ `S___. KANumber of lines________-/__________ __ Length of each line____��,___1_--,------------___ Width of trenchjex_�i�-__ Type of filter,matenal_ _____-___._Depth of filter material___aEl�_____•______.___Total length_____(a_' ______________________________ Seepage Pit:. Distance i`o nearest well----------------------Distance from foundation--------------------Distance to nearest lot line________________- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth----------------------------------N Cesspool: Distance from nearest well___-____________Distance from foundation-----------_--------Lining material__________________________- -_--_! ❑ Size: Diameter-------r-----------------------------Depth----------------------------------------------------Liquid Capacity- --gals. Privy: Distance from nearest well_________________ ___ __ _______._-_________._Distance from nearest building ------------------------- 1 ❑ Distance",to nearest lot line-------------------------- ----------------------------------------------------------------------------------------------------------- 1, Remodelingand/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 regulations of the San Joaquin Local Health District. (Signed)-- --------- 1- - ------------ (Owner and/or Contractor) By:-showi of to � -- --- - r (Title) r (Plot plan, g t, location of system in relation to wells, buildings, etc., can be placed on-reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------- - ------- r --------------------------------------- DATE - ------------------------------------------ `----------- - -- -- DATE fj ' ter / 1 i ----------------- BUILDINGNG PERMIT ISSUED--`----- ------------------------------------------------ --------------------------------------- DATE------------------------------------------------------------- Alterafionsand/or recornmeri