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APPLICATION FOR SANITATION PERMIT Permit No. -•�- /•--� (Complete in Duplicate) Date Issued Application is hereby made to the Sen Joaquin Local Health District for a permit to construct and install the work herein descr;bed. This application is made in compliance with County Ordinance No. 549, 91 /q 47• Az?................. JCC ADDRESS AND 'OCATION.._. ""--•' � �-'-- Phone..........._............ ......... Owner's Name. ..... .... ...... ... .............._.... •.._..__...._ • Address._... - _..1 P..�.. - - •---........ ............._._.._............................Phone....... .......... .... .. -• .. ........ ..._. �. . Contractor's t lame......__. -- ... _ .......•............................ Installation will serve: Residence ❑ Apartment House ❑ Commercial Number of ❑ ❑ Trailer Court Motel ❑ Other Number of living units: -- .. _ Number of bedrooms .__-.. Number of baths ._----- Lot size ..I0•.• Water Supplr. Public system ❑ Community system ❑ Private� Depth to Water Table - . t' Her pen Character of soil to a depth of 3 feet: Sand ❑ Gravel Sandy Loam C3 Clay Loam V Clay C3 Adobe❑ C1 Previous Application �'No HA/VA: Yes ❑ No Made: Yes ❑ No New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: r 200 f (No septic tank or cesspool permitted if public sewer is available within ) �... .. ---- �¢..f ...Met�yel...��... 0...•Distance from foundat'on. Capacity../,04L-d Septi enk ante from nearesi well.. .. id depth..... - Or►' o. of compartments_.'. . . ..........Size-.�7a-�3�' L Distance from foundation 'f..'S_....Distance io nearest lot lin �..�••••- Disposal Field: Distance from nearest well .`�.. - � Number of lines... -------- -..-•..•......Length of each line....... of trench...Z�....................... .. ....Total length......�Q.............------....-•-- Type of filter materials &_Depth of filter material..._..f-$.._.. Distance from foundation...I.-I..Q....... Distance to nearest lot Seepage P Distance to nearest well ....�ro� apth o. •--•—Size: Diameter.......3�a 3 3 Number of pits-.�..... _......Lining matert��.-•---- or" Distance from nearest well.........-.......Distance from foundation. Lining material.._................................. Cesspool: ...Liquid Capacity. ......................... ❑ Size: Diameter. ... Depth................... _-..-.. ... 1 Distance from nearest building__.......... ..........._-.-....•••Distance from nearest well..... ... _. .. . ........... Privy: ...................... ❑ _.. .._........................... Distance to nearest lot line..--- . Id Remodeling and/or repel ............................ . ............. County ............. ..... ...............__..._._........ ._..._.. _....._ . ............................................................................... that done I hereby certify that I have, prepared regulati ons o olf the Son t Joaquin hLocalkHealth eDistr District. accordance with San Joaquin ordinances. State jem ,es,4111ii- Contractor) . (Signed) ..� klev w ... .1 ./ By:.......... .. ........ ....... (Title).. ' �fk/u . . .......... .. (Plot plan, showing site of lot, loca ' of system in relation to walk, buildings, ate., can be pleas on reverse side). _ _ FGR DEPARTMENT USE ONLY _ — --_— DATE_ APPLICATION ACCEPTED BY : DATE -,' ♦` -. • .. - - ... .... P.EVIEWFD BY _. L DATE _. BUILDING PERMIT ISSUED ...... ..... _. .. .. Alterations and/or recomm e .-- i A' N'_PEC'TIC'1 BY: SAN JOAQUIN LOCAL HEALTH DISTRICT 172 Sycerwere Sheet 114 North •'C" SlrMl 700 West Oak S,reel ernia Tracy. C4130—is w Sc.th A ;Crile Shea! sAa0ece, C Iil CoMoreia Lod;. Caflorn4