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\V APPLICATION FOR SANITATION PERMIT Permit No ___ (Complete in Duplicate) f =/ 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. I JOB ADDRESS AND LOCATION_]?, __ � �_ Owner's Name ' gS � = -- - ----------------- - --- Phone------------------------------------ Address-------------- ----•------------------------------ Address-------------- - Contractor's Name--- S �� - Y. "`�' - ,1- -------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence E] Apartment House ElCommercialX Trail o rt ElMotel ❑ Other El Number of living units: -------- Number of bedrooms _--___-_ Number of baths -___ Lot size Water Supply: Public system J4, Community system ❑ Private [] Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sandy Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay ❑ Adobe•❑ Hardpan ❑ Previous Application Made: Yes ❑ No 9— New Construction: Yes'No ❑ FEMA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearest well_--�- -- 'stanc from foundation___ _ -a -- - D _ r I�------ Ma erial-------- --- No. of compartments----y------.- Size--3 � `. -------Liquid depth----�-----------------C.apaeitY----- -- - --- -- /�� ,� i Disposal Field: Distance from nearest well _A_ 1--w Disfance from foundation____1--Ci--- Distance to nearest lot in .-___� V.. { Number of lines________ __":_-Length of each line______�_4_ _'-_ Width of trench '_ _ "1 {� Type of filter materia3l p e th of filter matenal____�_ss_7_._______Total length______-1_�__Q__________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line------_.-_____.__ ❑ Number of pits--------------- ----Lining material-------------------•---Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining ma-terial_____._`_______-_-.__-__-_________. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity gals. ---------------Distance from nearest building----------------_------------- Privy: Distance from nearest well______________________ _ ❑ Distance to nearest lot line----- ----------- -----------•--•------ ----------------------- ----------------------------------------------------- -- --------- E Remodeling and/or repairing (describe):----------------------------------------------------------=--'---------------------------------•-------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------•------------------- ------------•--------------------------------------------------------------------- --------------------------------•----------------------•-----•------=.._..-----• - --•---- --------------------------- ---------------------------------------------------------------------------------------------------------------'�---------- ---------------------------------------------------------------------------------- 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)------------4-•44t- ---------------- --• _ _ _ - (Owner and/or Contractor) By:.----- (Title)----------------- - -------------- � (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- ----------- ----------------------------------•-------------------- DATE----C-------------------------- REVIEWED BY,-------- ---------------------------------- ------------------ ------------------------------------------------•-------- DATE -------~- BUILDING PERMIT ISSUED-------------------------- ---- DATE- ----- _ ------- Alterations and/or recommendations:------------------- ------------- -----l--• ------------------ - -------- ---------•------ -- ------- p -----------------------------------------•----------------------------------------------------------------------------------------------------•------------------------- --------------------•-----------•------------ ----- F€NAL INSPECTION BY:...... _S________ -� ______ L -) —big ---------------------- Date---- - --------------------- -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-7-2M Revisea ;-57 F.P.CO. ANN. _t -