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APPLICATION FOR SANITATION PERMIT Permit No. I ` _�� {Complete in Duplicate) This Permit Expires i Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and installery�+ork herein�Je--s7zribed, This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOC ATION-------s.__Z? _SR .._ _1.. a Owner's Name --------- ------------------------------------------ Phone..------------------------------- Address------------- Ih ------- Contractor's -----Contractor's Name ------------ -•- ------------------------- Phone---------------- -- Installation will serve: Residence �Apattment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units _ �- t' _-_ __ Number of bedrooms _ Numb�ofaths __-_____ Lot size _�Z � ��Wafer Supply: Public systeM [❑ Community system ❑ Privateth to Wafer Table _!D ft. Character of soil to a depth ik f 3 feet: Sand [Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: lyes ❑ No W New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic Tank:CK No of compartments--'-" 11 from well_� pis#ante f om found�jion__/0'►n"'~ G f -------.Mate i)l_- ---�---- Si star�ce-: - -�- J-_'-Liquid depth------- -------------Capacity------?�10��- Tram nearest well_5,4_�D' from foundation - f�istance to nearest lot I nre__ Dis Disposal Field: �urnbee of-lines__________ 5-e- I_ s Z -___ _ ___ __Length of each line______�_4- _ Width of french__.�-�__ Type of filter material-- r_-----------------Depth of filter material---.t ------------- otal length------- ---------------------- Seepage __________________Seepage Pit: Distance to nearest well_______--------------Distance from foundation-------------------- Distance to nearest lot line__<- ❑ Number olf�pits---------------- --"'Lining�rnaterial --_: .- ---Size: Diameter_----------------------.Depth_--------------- I ----------', 4 Cesspool: Distance frorii�nearest well---------------__Distance from foundation--------------------Lining material__ ------------- ---------- n _-__----- . __ ----- s ❑ I Size: Diam�i.eterl-------------------------------------Depth--------------------I_ Liquid Capacity Y 9-------------------- als. Privy: ; Distance from .nearest well------------------------------- ___------_-_-Distance from nearest bui)din Distance to nearest lot line_________ ------------------+ Remodeling and/or repairing (describe):-____--�._,. ________.----------------------- ------------•----------------•------------- ------------------------------------------- IMI - ` ------------------------------------------------------------------------------ ._I hereby certify that I have prepared this application an !.? ---------------------------------------------- -------------------------------------------- T d that the work will be done in accordance with San Joaquin County 1 l ordinances, Sfaf laws, and rules and regulations of the n Joaquin Local Health District.. (Signed)____ �i ---- -- ---- .. ------- (Owner and/or f OContractor BY: IF Title f ----- - ot plan, showing size of lof,,llocatian of systfemnin relation to wells,, buildings, etc., can be placed on reverse side). �- FOt DEPARTMENT 5E ONLY APPLICATION ACCEPTED BY__ ___ --- DATE_. - , 0 REVIEWED BY --------------- - ----------- ---------------- -•---------- 'DATE------------- ---------------------------------------------- BUILDING PERMIT ISSUED-----1�li------- ---------------------------------- DATE------- Alterations and/or recommendations_____________________________ _ IM, --------------------------------------------------- ---------- ----------------------------------------- ------ --------------------------------------------------------------- FINAL INSPECTION BY:---- I� ---- ------------------------- Date--------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi,.California, Manteca, California Tracy, California ES-9-2M Revised 8-'S9 F.?.Co. _�