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4 APPLICATION FOR SANITATION PERMIT Permit No, Wj (Complete in Duplicate) Date Issued _____ Application is hereby made to'the San Joaquin Local Health District for a permit to construct ad instal! the work herein described. This application is made in compliance with County Ordinance No. 549. �SO JOB ADDRESS AND LLOCAT1bl L'--(------------��- ,�G�©QO " " ' l�l ``-"� ' ------ --- Owner's Name r-la' C�1`' -"''_� --a----------- ------------ ------------------------------------ Phone---------------------- Address----� f �------ ---------------------- ---------------- -------- ------------------------------------------------------------- �f Contractor's Name--------- ----------------------------------------------------------------------- Phone----••-•------------•------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court. Motel ❑ Other ❑ Number of living units:I!_�V- Number of bedrooms _______ Number of baths -------- Lot size 1 ----------------------- Community _ ________________Community 'system ❑ Private Ej Depth to Water Table ft.Water Supply Public s stemx Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ! New Construction: Yes No E] FHA/VA: Yes E] No i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) .l Septic Tank: Distance from nearest well_ i,t c� from fo dot n___ Mate ial __________________________ — " � .I,& - ----- �( No. of compartments------�-------------Size' " j, _ ?.Liquid depth-------- -------------Capacity_ -r7±_ ___-- T i Dispo al Field: Distance f�om nearest well_ ce from foundation--16 __ Distance to nearestjot line..---. Number of lines____e_ r Length of each linew _ _ H !�. _r ________ _._1-__..___ �,_.Width of french---- ___-- -- .I. - Type of filter material__-S 7' .. epth of filter material_____ -____------- otal length_"_ _ __________ Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line----------------- � ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------- --Depth--------------------------------- a. Cesspool: Distance from nearest well----------------- from foundation------------ ------.Lining material------_____________.______________- Size: Diameter--------------------------------------De th_:__---------------- - --- ----------Li uid Capacify __gals. Privy: Distancefrom nearest well_____________________________________________Distance from nearest building------------------------------------------------ ❑ Distance fo nearest lot line--------------------------------------------------------------------------"---------------------------------------------- --------------- Remodeling and/or repairing {describe)---------- --------------------------------- -- -------------------------------------------- -GI1 --- ----- -----A---�LI(2---� �--------------------------------------------"--------------------------------. { ---. -------------------r --••------------------------------------------------------------------------------------------------------ IM I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, StateAaws, and rules and regulatio of the San Joaquin Local Health District. (Signed)-- -------- r �I� (Owner and/or Contractorl By:-------- .----i--------------------------------------- -------- (Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse_ side). JN FOR DEPARTMENT USE ONLY ,M APPLICATION ACCEPTED BYDATE---------------------------------------------------------- -- ------------------------------------------------ ----------- ---------------------------------- REVIEWEDBY------------------------------------------- - ------------ ------------------------------- DATE-----------/ BUILDING PERMIT ISSUED--- ---------------------------------- DATE-------------------------------------------- -------------- Alterationsand/or recommendations------------------------ ------------ ---------------------------------------------------------------------"•--•-----•"-"----------------------- ------ --------------------------•---------------------- 1M----------------- -----•------------------------------------------------------•-----------------------------------------------------•--------- -----------I--------------- ---------------------------------------------------11 --------•--------------- IM ------------------------------------ ---------------------------------------------------------------------------------------------------------------=------------------------------- I - --------•-------------------------- --------------------------------------------------------------------- ------ - -------- FINAL INSPECTION BY---------------- --- - Date-------- _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California g 1 ES-91-2M ,- Revised 1:57 F:P.CO.