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APPLICATION FOR SANITATION PERMIT Permit No. ..�.�_..!_........ I L� (Complete in Duplicate) ll!! "1 Date Issued .` G.. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herei�;�Thisapplication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOC ON------------- ---�-- _ _ - _ ___-- ------�-----�---• �..---�------ - -- � 1�__._•--,._ Owner's Name------------ Jam!-�/'L ------ - one....................................� r Address----------------------------------------- 1--{ l � 1 C` 'L Contractor's Name-------------------------------------------------------------------------------------------------------------- ............. Phone................................... Installation will serve: Residence �partment House ❑ Commerciar �t Trailer CourtMotel [:] Other C]Number of living units: _f_--_ Number of bedrooms _.L__ Number of bats _./_ Lot size,___---Q..cc S-___X__.Z_Z__O__.............. Water Supply: Public system ❑ Community syste ❑ Private Depth to Water Table _16_._ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ Na New Construction: Yes 2-INo ❑ FHA/VAiYes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFIdATIONS: (No septic tank or'cesspool permed if public sewer is eveileble within 00 feet.) _ Septic Tank: Distance from nearest wel JU stance from fgun ion�4� aterial__ /�. _____________ No, of compartments------�/------------Size__�_�-�_X___�-....._Liquic�-depth_-__1'-- ________Capacity . �__ __.. Disposal Field: Distance from nearest'`We�l_-l-D_/':_Ulstance from foundation,-:,_Z. ._.Distance to nearest lot Number of lines__________i� _ Length of each line----4e.�------_ Width of trench___c .5�___�_____ ___ Type of filter material___ Depth of filter material_____f Total length------,l.'�� ________........ ____ Seepage Pit: Distance to nearest well _________________Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits--------------- m'aterial_=---------------------Size: Diameter_....................Depth................................. Cesspool: Distance from nearestw'll __________Distange from foundation _--------------.1ining material------------------------------------- ❑ Size: Diameter----------- --+-- -,-------------Depth--i-------------------------- ------Liquid Capacity-------•.__ ••-gals. Privy: Distance from nearest well------------------------------------------------- Distance from nearest building____________________•:___.__,_-___-__-.,_. ❑ Distance to nearest lot lire-----------------------------------------------------------------•------•---------------------•---•-----•--------------------------------- Remodeling and/or repairing (describe) ------------------ ......................................... -•-• •---•---•-----• --•--•- -- --------------------------------- ------------------------------------- ---- ------------•--- ---------------------•--•--- i ----------------------------------------------------------------------- -•----•-----•--------------••-•-- ---------------------------------------------------------------------- -----••---------------------------- I hereby certify that I have prepared this application and thlat the work will be done in accordance with Son Joaquin Coun ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) _.2y_._ _ ___,_____.._(Owner and/or Contractor) B .. ...-----•--•--•••---.......----------------------------- (Plot ----- •--------------•-(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse sidej. F0 D ENT ONLY APPLICATION ACCEPTED BY----- ----- -- •--- ------- • ------- ATE.... ••• -•- ................ REVIEWEDBY-------------------------------------- - ------------------------------------ DATE..................................._.-----•-------•---_---•- BUILDINGPERMIT ISSUED..............................................................--...................................... DATE......................................---------_---------- Alterationsand/or recommendations:...--------------••----•-------------------•--------••-•----•----•---------••-••--•-----••---•.-•----------•-•--._....--------•.______.__----••--------------• -----------•------------------------•-------------------------------- ------------------------------------------------------------------•••--------••-----........................................................ --•-•••------••••--------------------------------------------------------------------------------------------- -•----------•-•------•---•---•••---•--•------•--••••------••-•----•---•---•--•----••-•-•-•••-••-•----•-, -----------------------••------------------------------------------•--------- ----------------------------------------------------------------••--•-•------------ -------------------A -•------------------------- - FINAL INSPECTION BY:...- -------------------------------- -- Date...... ..liG ..................... 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 , Revised 1.57 F.P,CO.