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FOR OFFICE USE: - ------------------- ---------------------- -------------- -W,r �/ _.--_________---__ .._- --------- APPLICATION FOR SANITATION PERMIT Permit No. __l-��U., -------- ---------------------- --- ----------------- --- (Complete in Duplicate) / =; This Permit Ex ires I 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. JOB ADDRESS AND LOCATION .. _ -- ---------------"---------------_--- --- ----------- --- -- - -------------------------- 11 Owner's Name _ °"t ft;----------•---•-------- - - - ----------- Phone--.. - Address - ------ ---------------------------• ------------------ Contractor's Name._ij � - ------ Phone---------------------••------- - Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths ________ Lot size __.-"_--__.__"____________________ -------------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth'of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: -(If yes,date------------------- No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: No'septic-tank=or-cesspool-permitteA-'if public sewer"is availali1e witfitn`200 feet.}""a"� _}' � "a"' Septic Tank: Distance l!from nearest well-----------------Distance from foundation--------------------Material ❑ No. of compartments--------------------------Size--------------------------------Ciquiddepth-------------------------Capacity----------------- Disposal Field: Distance ;from nearest well__tr. ---------Distance from foundation__&------------Distance to nearest lot lines-__..----- Number of lines.Rp ...... 'I--Length of each ------------------Width of trench..�.�--'!._______..__---_""_-- -------------- Type of filter mafieri "_Depth of filter material"___--�,9_'!_--__._Total length----"Lj'p'____._.." Seepage Pit: Distance to nearest weI----------------------Distance from foundation--------------------Distance to nearest lot line--_"___._-._____ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth_ ----------------------------- Cesspool: ----------------------- --- Cesspool: Distance from nearest well-----------------Distance from foundation---_----------------Lining material------------------------------------- Q ElSize: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: � __DistanceJrom nearesf�well-------------------------------------------------Distance from nearest building___._____.__.____" -" ❑ Distance :to nearest lot line------------- - � ��,,// -------------------------------------------------------- Remodeling and/or repairing' (describe):--447 _/,moi �yy� ---------"-•-------- --------------------------- -----------------------------------------------------------•----------------------•------ -----------• ---•------•---------••-•--------•--•--------...---------------------------------------------------------------------- --------------------------------------------------=--•---------------••---------------------...-----------------------------•---------------------------•---------------------------------------------------------- - 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. 14- (Signed) !-! F-- s�-'�-`�kL_ ------ --- - ------- - �.:,.. = - r on ract By: - �..._.. . ,�_.. ---- --- -- -------- --------------------- -- caner an . (Plot Ian. showing size --.-------- --�—:—•s— � -_{Title) " o C