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APPLICATION FOR SANITATION PERMIT Permit No. ____."_Y___' _.... (Complete in Duplicate) Date Issued ___�� //S-_.�_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install thheo herein described. This application is made in 'compliance with County Ordinance No- 549.{ 1 . _,� /� , . JOB ADDRESS AN OCAT ON__ Owners Name--------- ---- -------------------------------------------- Phone------------------------------------ ---- ------ ----- ------- ---------------- - ---- -- - -- - Address.--• - --------------------------------------------------------------- -------------------•-------=..................................... Contractor s Name-•- -----•---------------= =----------------------------_-------------- ------------ Phone Installation will serve: , Residence [+]Apartment House ❑ Commercial ❑ Trailer .Court ❑ Motyl ❑ O her ❑ Number of living units: J____ Number'of bedrooms __ _-Number of,baths _1__ Lot size __ __ __ _ _. . ___.___-_________ r Water Supply: Public..system,El ...Community .system ❑ Private I/Depth to'Water Table -------- ft. d � Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay.Loam ❑ Clay ❑ Adobe Ig{ Hardpan ❑ Previous Application Made: Yes ❑ No DK New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic sewer is available within 200 feet.) } s S ti, Tank: Distance from nearest well____ __Q__ Distance from fouydation___�a_;_-_____.Materia____ --- __ __ _ No.;of com artments_- Li u�d de S e a - �� Capacity p q ---------- .. f Disposal Field: Distance from nearest well_ stance from foundations � '-Distance to nearest)ff��t,�!'n [►� Number of lines_________A ___r._ Length of each line_________.,,_ iWidth of french_____/+�_�_ rf... 1-- Type of filter materia .__' epth of filter material---------- _t -------'Total length_____________�__ _______.___..____ f Seepage Pit:-M Distance to nearest well _ ____Distance from foundation_._..._..___....___.Distance to nearest lot1ine_____-_-___-_____ ❑ Number of pits.---:'---- ------Lining material---_-_-_- __------Size: Diameterf-------- ------ -.Dph----------------_-------__.------ Ir-" -_ Cesspool: Distance from nearest weil_______________t_Distan.ce from foundation----------------- _.Lining material"___._______________________________ ❑ Size: Diameter---- - ---- -------Depth---------:-------------------------------- -----5 Liquid Capacity---------------------- -----gak Privy: Distance from-nearest well_-------------------------------------------------Distance from nearest building_________________________.____.______- ❑ w` •stn -t n s lot I n ------------------------- - ------------ ------- --_------------------------ ------- ----------- _. . Qi ace o eare t o e_-__ -�_ w Remodeling and/or repairing (describe):'-- ------------------- -------------------------------------------------••--------------------------=-------- ...........---------------------------- -------------------- --------------=---------- r. 1 F -----------------------------••------•••----------------------------:-----••-----y-•-------------------------------------7--------------------------------------------- --r--- --------....-------------------------------- ` t� v I hereby certify that I have prepared this application and that the work will be done in-ecc�oedance with San Joaquin County. ordinances, State laws, and rules and regulations of the San Joaquin°Local Health District. (Signed) '!� --"" ------�---------------------------------- --- (Owner and/or Contractor) }}d...,............ i - By----•---------------- ---------------------------------= = — = {Title} i (Plot plan, showing size of lot, location sof system in.relation to wells, buildings, etc:, can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION REVIEWED BY_-ACCEPTED BY _j ._ .: i - - DATE - ------------------------------------i BUILDINGPERMIT ISSUED---------------------------------------- ---------- ----- --------------------- DATE---------U_% --------------------------- ------------------ M Alterati s nd/or re mendations:---=----------------- -- - ------------------------------------------------------------------- -•---:.-.-.. -. - -- - _490------ ---------------- -•-------------- --------------------------------------------------------------- --- --- ----- ------ ----------------------------- FINAL INSPECTION BY:_.- '` --------------- r_.._ Date-- =- =� = -------------------- JOAQUIN LOCAL HEALTH DISTRICT . l 130 South American-Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street d Stockton, California Lodi, California Manteca, California Tracy, California am- ES-9-2M , Revised 1,57 F.P.CO. a'