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APPLICATION FOR SANITATION PERMIT Permit No. _-_.__-_ n (Complete in Duplicate) rr`�U S (�( Date Issued ______________ __ 111111��` 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 SLOCATION _5 L_ � Owner's Name ' V-- ----------------------------------- ------ Phone------------------------------------ Address------ ---- Z-0-P---=- --- ----- ------- - - - --- - ------ -- - -- ---------------- --------•-------------------------- - s � Contractor's Name--------------- -------------------- Installation +�__ _ Phone Installation will serve: Residence R2-'_Aparfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/.__ Number of bedrooms -A- Number of baths _ __ Lot size0-________________------- Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Table'-'W44'. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan❑ Previous Application Made: Yes ❑ No [k-New Construction: Yes ❑ No E�-�HA/VA: Yes ❑ No [g',* TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) �eptic.Jank: Distance from nearest well-_____________Distance from foundation____----------------Material__:------_-_________._______________..._---_.__,. No. of compartments--------------------------Size------------------------------- Liquid depth---------- --- -----------Capacity----------------------- Dispos field: Distance from nearest well_---------------- Distance from foundation--------------------Distance to nearest lot line----------------- N umber ________ ______Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter_ material-----------------j--Total len"gth-------..---------------------------------c• Seepage P•t: Distance to nearest well �__-Distan frpm ou tion.,400..-__.. -s r�� to nearest I liri Number of pits._._______------Lining materi ��' ize: Diameter_ _____.____Depth . "'---- Cesspool: .__ .___ Cess ool: Distance from nearest well_________________Dist ce from fon SS p • dation----- --------------Lining material---------------------------------- ❑ Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity-.--------------------------gals. 1 \ Privy: Distance from nearest well ______________________________________________Distance from nearest building------------------------------------------ ❑ Distance-to nearest lot line:_ ------ --- ------ ----- ------ ----------------------- f Remodeling and' or repairing (describe):----- ---------------------- ------ ------ --- i -------------------- ----'- '----------- -•------------------------- ---------- ----- - g --- 9 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, a rules and re ula ns of the an Joa uin Local Health District. (Signed) - ------- -------------- By:----------------------------- --------------- - - -- --------------------------------------------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of, location of system in relation to wells, buildings, etc., can.be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ------------------- ------------------------------ DATE----------------1 REVIEWEDBY--------------------------------- - ----------------------------------------------------------- DATE-----=------- BUILDING PERMIT ISSUED---------- 'b = ---------------------------------------- DATE--------L�---------- Alterations and/or recommendations:-------------- --------------------------------------•-----------------•-----------------•-----•-------------------- --------------------- ---•--------- ---- ------------------------------------- --•--------------------------- ------------------------------------------------------------------=-------------------------------------------------•--------- S=7 k ef--------- -------- -------- ---------------------------------------------------� r--�------------------ - FINAL INSPECTION BY:--------- `- � 4' -- Date________________17 -` ----�/-------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21x1 , Revised 1-57 F.P.CO.