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_ r APPLICATION FOR SANITATION PERMIT Permit No. ._ d___ (Complet D Iica//t��) � i��•Grur Date Issued ---.------�j/-S� Application is hereby made to the San Joaquin L al Health District for a permit to const t and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS ANDfLOCATI NI ---------------- ' d v Owner's Name--� - --- ---�Ati-1✓------ - --- - -------------- ---- -----------------•`------ ----- ----- Phone------------------------------------ Address ------------------------------- thy ✓ fT Contractor's Name---------------- st ---------------------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other++ El Number of living units: __/-.-- Number of bedrooms .1 Number of baths . Lot size , -�_Q___ LJ.7o---- ----------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 8-Clay Loam ❑ Clay ❑ Adobe❑ Ha*an ❑ I Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) 1<2 _ Septic Tank: Distance from nearest well_________Distance from foundation__/V______.-_�terial..r ____ __ ___ __ No. of compartments_-_r;?-.-.�-____-Size_,,3_X__f�_._��Liquid depth-____-.�-_--______Capacity��__----- Disposal Field: Distance from nearest well___ - -!L_._Distance from foundatio �...Q-__--_._Distance to nearest lot line_________________ Number of lines----- _` __ Length of each line----- _ -_- Width of french_:__._r�_, doop Type of filter material______ _- ___Depth of filter materia____ ___-___--Total length.----- ______________ Seepage Pit: 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_-______-__________-_______-_________- 3 ❑ Size: Diameter------------------------ ------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______________.___-_____________________- ❑ Distance to nearest lot line-------------------------------------------------------------------------•-----------------------•--------------------------- - §� Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------- ------------------------------•-------•---------------• --------------•----------------------------:----------------------------------------------------------------------------•------------------------------------ -------------------------•----------•- ------ -----------------•--------------------------------------------------------------------------------------------------------------------------------------=------------------------------------ ---------------------------- ------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed)............. ----------------------------------------------------------------------------------------(Owner and/or Contractor) By:-------- = -----------------------------------------------------------------------(Title)-------------------------------------- ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------------------- --------------------------------------- DATE.---- --------- REVIEWED BY----------- ------------------ - ------ -- -- DATE-------- ---- BUILDING PERMIT ISSUED------------ - DATE------ ----------------------------------------------- Alterations and/or recommendations: ------------------------------------_---------------------------------------------------------•------------------------------------------------•-----------------------------•------------------------------------•.---•-- ------------ -•-•-•----------- ------------------------- --------- -------•-------------•-•----------• - ------------------•---- -------------------------------------------- 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 ES-9-2M Revises 1.57 F-P.CO.