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)0yW6 ' Permit No ------ ----------•---••- APPLICATION FOR .,,ANITATION PERMIT _ ' (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his application is made in compliance with County Ordinance No. 549./01 - -------------------------------------------------- _ JOB ADDRESS AND LO ATION____-____-1 ------- f Owner's Name------ 2•- Phone- ---------- Address-...------ ------- --- --------- - •- --------------- - on Contractor's ame_____ __ - Installation will serve: Residence artment House I[]. Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of bedrooms �-- Number of baths __.j__- Lot size _.-_ �-------------------- Number of living units: --� Sft. Water Supply: Public system 0- Community system ❑ Priva#e ❑ Depth to Water Table �_Cl - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No J6 New Construction: YesZ No ❑ FHA/VA: Yes ❑ NoX 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-----------------Distance from foundation--------------------Material------------------------------------------------ . No. of compartments_. Size-•------------------------------Liquid depth--------------------------Capacity..--------------------- Field: Distance from nearest well_-_---_--_-_---.Distance from foundation_--------__-_.----Distance to nearest lot line----------------- p ---------Width of trench � Number of lines-----------------------------------Length of each line--------------------- .Type of filter material-------------------------Depth of filter material-----------------------Total length----------------------- -- \ SeeCS p ge Pit: Dis#ante to nearest well Distance from f na`ation_--,1�. -.---.Distance to nearest lot line____ __________ .✓ ----------- Number of pits-------/----------- Lining material Size: Diameter_-- - -------Depth-.------- - ol 4 Cesspool: Distance from nearest well-----------------Distance from foundation------------.------Lining material--._____-________._____.____-_.-._- � Size: Diameter--------------------------------------Depth---------------------------------------° ------- -_-Li quid Capacity- --------- ---- ---._--gals.- ❑ Y Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ------------------------I---------------- ❑ Distance'to nearest lot line._ -------------------------------------------- - 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 I ordinances, State laws, and rules a regulati ns of a Sa oaquin Local Health District. . -------------------------------(Owner an /or Contractor) I (Signed} t! = % "�g`" r d -y `f (Title)- By: Title By:-------------- r (Plot plan, showing s" o , to n of Sys em in relation to wells, buildings, etc., can be p aced on reverse a}. FORD RTMENT USE ONLY I APPLICATION ACCEPTED BY------- -- - - --- ----------------------- DATE--- ti-------------- ----------------------------- REVIEWEDBY---•------------------- ------------------------------------------------•----------------------- BUILDINGPERMIT ISSUED-------------- -------------------------------------------------------------------------------------- DATE------------------------------- ---------------------------- Alterations and/or recommend tions--------------- --- --- -- ------------- --- -------b------------------------------------------I--------------------------------------------------------------------------- ----------------------------------------------- 1 ------------------------------------------- ----------------- - -- - --------------------------- - ------------------------------------------------------ -- - --- ) _�LC " S ' ------- Date---- -------�--- - -------------- -------- (II L INSPECTION BY:___ --- ----- ------------------------ - SAN JOAQUIN LOCAs. HEALTH DISTRICT a 130 South American Street 300 West Oak Street 132 Sycamore Street 814'North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 3 ES-9-2M , Revised 1-57 F.P.CO.