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' APPLICATION FOR SANITATION PERMIT Permit o. _ (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. This application is made.in compliance with County Ordinance No. 549. JOB ADDRESS A LOCATION...____ -1 �Y ----------- .- -- --------------- Owner's Name s G•--L-F�_1. _. -------------------------------- --------------- ------------ Ph6ne------------------------------------ ss--�� ry T Addressrte: r� �----------• -------------------------------------- �•------- - ------------------------•----••--•---- Contractor's Name----- -- - t +r� --•----------------------------------- ••-------------------•--- Phone----------------------------------- Installation will serve: Residence 9,-,Kpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----- Num ber of bedrooms _umber of baths .f._. Lot size ___.. ---------------------- --_____________________ Water Supply: Public system Community system ❑ Private CJ Depth to Water Table�� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 92 New Construction: Yes JQ_ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: tante from nearest well_________________Distance from foundation________.____.____.Material------------------------------------------------- El _____..-________.__ -___________.__________-.❑ f.compartments-- ----------------------Size---------------------•---------Liquid depth------------------------_Capacity------------------------- Disposal Field: nce from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line-----'-----.----- ❑ r of lines-----------------------------------Length of each line-------------------------------Width of trench.--------------------------------- T e of filter material-------------------------Depth of filter material-----------------------Total length---------------------------------------- Seepage -----------------------------------•--Seepage Pit: Distance to nearest well___-&_ _0_)-%.Q-0istance from fouadaa ion_=._l> _'____-Distance to nearest lot line--,;Fd__ Number of pits---- --------------Lining material--- � _ c•�!S Diameter-- -t/---Depth-_-��„5---------------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material______--_____-_____.______.__.______- p ❑ Size: Diameter --Depth---------------------------------------------------Liquid Capacity----------------------------gals. I Privy: Distance from nearest well________________________________ ___________Distance from nearest building ❑ Distance to nearestlot lire------------------ -=------------------------------------------ ----------------------------- Remodelingand/or repairing (describe):------------------------------- -------------•-----------------------•-------------------------•------------------------------------------------------- - -----------------•----•--------------------------- --------- -------------------------------------=-------------------------------------------------------------------------------------- ----------------------- -------------------------------------- -------------- •--------`------------------------------•----------------•--------------------•-------------------------------------------------------------------- --------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County . ordinances, State and .rules and regulations of the San Joaquin Local Health District. , (Sig ---- ----- - -- - ---------- ------- ----- -- - ----------------------------------------------------------------(Own and/or Contractor) - By: r- -----------(Title)-- ---- ------••--------------------- (Plot plan, shoring size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------- ------------------------------------•-••------------- DATE----- REVIEWED BY- - ------- --------------------------- DATE BUILDING PERMIT ISSUED----------------- ---------------•---------------------- •------------ DATE------- = ' --------------------------------------- Alterations and/or recommendations:_________ ______ ___ __ _ - --------------------------_-------------=_::_____:_:::::::__:::_:-----------_------------------- ___- -----------------•-•-• -- -- -- - --- --•--------- --------------------- -f -5 FfNAl, •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 ES-9-2M Revisea 1-57 F-P.CO.