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Permit No. � APPLICATION FOR SANITATION PERMIT ...................,�!. A a (Complete in Duplicate) Date Issued V Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND O ATION--------- -�1 ---•------ , Owner's Name ---- --•- Phone Address------------ --------- ------ - --- -- -- --------------------------------------------------- ------------------------- ------------- Contractor's Name-----------------------•____-- ; !7a OV10 7--- ---------------------------------------------------------------------•--------•--- ----- - ----- Phone--• �/ Installation will serve: Residence [e"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedroorris __ Number of baths-_/__ Lot size __ ¢d X -------------------- Water Supply: Public system ❑ CoE munity`system'❑"' Private"�]epth to Water Table .S-'o_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam El Clay E❑ Adobe C]Hardpan Previous Application Made: Yes ❑ No gj--New.Construction: Yes ❑ No [9!FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) # tir~ k: Distance from nearest well_________________Distance from foundation-----------__------.Material-------- _--_-.-_--__------_._______..__________- No, of compartments--------------------------Size--------------------------------Liquid clepth------------------------ os G d: Distance from nearest well..................Distance from foundation_________________.Distance to nearest lot line.-___-__._______- Number of lines ----------Length of each line----------------------i----- Width of trench----------------------------------- Type of filter material-------------------------Depth of filter ma#eri --------------'_-----Total length-[-----.--_.__--------------------._------ Seepage Pit: Distance to nearest well/-----------Di an from foun etion__ -_.___.___.Distance to ne a ne `�� - - Number of #s____.� Lining m erial . ___ ize: D meter____ ____..___Dep __O� _--_ _ I� p• -------- Cesspool: Distance from nearest well--=�--_---D ante from.foundat_ ____________________Lining material------- ..___--__--_.--____.___ ❑ 'Size: Diameter------------ ----------I --------Depth---------------------- === r---------------------Liquid Capacity----•----------------------gals- Privy: Distance from nearest well-----_y_-----------------------------------------Distance from nearest building- --------.______________________________- ❑ Distance to nearest lot nine_,_____:,______________ Remodeling and/or repairing (describe)--------------------------------------------------------- ------------------------------•-•-------•------------------------------------- ---=----------------------------•----------••-------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------••-•----------••------------•---------------------------•---------------------------------------•------------------•---------------....---------------- -------------- ! hereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e I s, and rules and regulations of the San Joaquin Local Health District. Si ned - ---------------- -- -.-------- .- .-- -------------------------------------------------------- Owner and or Contractor ( g )--------- - ( / ) By------------------------------------------ � (Title)- 4 (Plot plan, showing size of lot, location of system in relation wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY------- - ---- -------- --------------------------------------------- DATE------�------=-=_ ---- ---------------------- REVIEWED • -- REVIEWED BY DATE. -- - - - --------------- BUILDING PERMIT ISSUED------------------ ----- ----- DATE. ------ Alterations and/or ret mmendativns: - -------- ------------------ ------- ------------ -------- ------------------ -- w _ __ _ _ _ - ---------------- -------- _ � ll``:� ---- ---- - ------ ------- - ' ---------------------------- ------------------�------------------------•--------------------------- --------- --------------------------------------•--------- ---------------------- - ---------------------- -------------.....---- FINAL INSPECTION BY----- --- --- - ------- -------------- -------------- Date---T' Y�..- ------------------------------- 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 ES-9-21M, Revisea 1.57 f.P.CO.