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APPLICATION FOR SANITATION PERMIT Permit No. ...11...5_ = (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 County Ordinance No. 549. 706 ADDRESS AND LOCATION... _ Xv - y' , ------------------------------------------------------------- Owner's Name--------- t------- all2' Phone ------•------- Address---------- _01 ------------••----------------------------••--------------------------------------------------------•-------•-----------------•-----•-----•---------------------------------- Contractor's Name-------------` ____.____ Phone________________________ Installation will serve- Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court 2110MIfel ❑ Other ❑ Number of living units: _Z_. Number of bedroo s _+P__ Number of baths __ Lot size __.�___lE ---- ---------------------------- 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: Yes ❑ No New Construction: Yes ❑ No Wa--"`FHA/VA: Yes ❑ No 12--' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep.tic Tank: Distance from nearest well________________Distance from foundation----------------.- Material----.---____---___-____--.--___--_-.-----------.. . �[y f No. of compartments--------------------------Siie-----_------------------- ---Liquid dep�h--------------------------Capacity-------------------- r Disposal Field: Disfance from nearest well_________ _____Distance from foundation____ __©_________Distance to nearest lot line...t'_P---._.. 91 rr � f Number of lines----- Length of each line___._____) ____ __________Width of trench_ __ m t` �. Type of filter material-------------------------Depth of filter material-----/6---_--------Total length---------- Jr __-- -----------_-----____-- Seepa,9 Pit:, Distance to nearest well-____-'-�`�'_____Distance f am foundation___.fP-__ '_.Dista��e to nearest lot lin .~ Number of pits___.__,____________Lining material _ Q�, 'rSize: Diameter_. _.______Depth_._._. __________________ M � Cess% o . Distance from nearest well-----------------Distance from foundation..______________.Lining material__.______________._______________. - ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity- -------------------------gals. A Privy: Distance from nearest well-------------- -----------------------------------Distance from nearest building___._.____________.____-_____..__.._____- ❑ Distance to nearest lot line---------------------------------- ---------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):° µ - �__ _ ---------------------------------- -- ------•---- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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. —4d (Signed)-------------- , r --- ----------------� I .� ___ ��_ or Contractor BY= - -�------------------------ (Title( f --�� --- - ------------ (Plot plan, showing size of lot, loc n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY n APPLICATION ACCEPTED BY---- -------------------------------------------------------------------------- DATE---- ~----------------------------------- REVIEWEDBY-------------------------------•---------------------------------- ---------------------------------------------------------- DATE-------------------•-••-----------------------•----------- BUILDINGPERMIT ISSUED--------------------------------------------------------------—-----------------------------------.-- DATE---------------------------------------------- Alterations and/or recommendations:---------------------------------------------------------------------- .-------•------------------•--------------------------•--------------------------------- ------------------------------- ------------------------------•-------------------- ------ ------ -- ------------------------------------------------------------ ------- -----•- ------�------ ------------------------------------------•-----------------•----------------- ----------------------------- --------------------------------------- -----•---- ----•- ----------------- ------------------------- t FINAL INSPE ON BY-- - - - - ---- ------- - ---- -- --- Date_ --------J - -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street S+ockton, California Lodi, California Manteca, California Tracy, California ES-9 2M Revised V59 F.P.Ca.