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/ APPLICATION FOR SANITATION PERM IT Permit No. ___1__-.-:---� (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins all the w rk erei�scribe . This application is made in compliance with County Ordinance No. 549. �� Gc.. eD�P—�'t-d D ,S 'j—• - JOB ADDRESS AND �Lq CAT ! --- 7a'` Owner's Name---------- ------------- _____________ _ 1---� ---_ - --�----- ---------- - ff - Phone_ -------------------------------- Address -•-------•-- --•----------------------------------------------L Contractor's NamePhone--, ��6a _ -•-------- ., Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. _ -_- Number of bedrooms -1--lNumber of baths _L___ Lot size /00- _ 3C - -- -------------- Water Supply: Public system ❑ Community system p Private U?15e`pth to ater Table , ffi. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam Clay Loam E] Clay ElAdobe ElHardpan C]Previous Application Made: Yes E] No ZK New Construction: Yes [] No ❑ FHA/VA: Yes ❑,d=No, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if �crsewer is available within 200 Septic Tan Distance from nearest v�ell_______________ Distance ��m o c�jt�on -----Q.-r--_- Material____._-__________.___--..---No. of compartments-- Siz�_-- --•- .-----Liquid depth_�!----------Capacity_ e0------- Dis osal Fi Id: Distance from neare t well-'_ O�Distance From foundation__ ___ ' _____Distance to nearest lot line__!-d_-7- ------- .____ p Number of lines----- .___Length of each line_ __- !/..Width of trench._ ---------------------- ---- Type of filter materiaa �__Depth of filter material___.__ ______Total len th____ i g a 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 material-------------------------------------- 0 Size: Diameter------------------------------ , Depth_.-------------------------------------------------Liquid Capacity. -------------- ---------gals. Privy: Distance from nearest well--------------------------------- -----------Distance from nearest building6 ❑ Distance to nearest lot line------ --------------------------------------------------------------- ------------- --------------------- Remodeling and/or repairing (describe):_______________________________ r ---- -------------------------------------------------------•------------------• ---------------------------------------------------------------------------- V)---------------------- --- -----Lfha+ ------------------------------------------•------------ --------------------------------------------------------------------•------------••---------------------------------- I hereby c rtifve prepared t 's application and that the work will be done in accordance with San Joaquin Countyordinances, Sta larauleand regul ons of the San J aquin Local Health District. (Signed) - ------ - - or Contractor) ------ - ------------------ - -- By:----•-----------•------------------•-•-------------------- Title (Plot plan, showing size of lot, location of system in re la o o wells, buildings, c., can be PI cad on reverse side). .� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- DATE ------------- REVIEWED BY - Jt, --------------------------------- DATE---- r BUILDING PERMIT ISSUED------------- �i - ------------------- ----------------------- DATE ------------------------------------ A terations and/or recommenda+ions:_________________________ ___._ -------- -- --------------------------•--------------------------•-------•----------•-----I----------------------------...-------•------ ------------------------------ 7 --------- FINAL INSPECTION BY:__- --- -•-t---- ------ ------ - ----------- Date----- - - - -- �--�- �---------- --------------•--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reef 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street Stockton, California nodi, California Manteca, California Tracy, California ES-9-2M ; Revises 1.57 F.P.CO.