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APPLICATION FOR SANITATION PERMIT Permit No. ....G�................. r (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 d d, This application is made in compliance with County Ordinance No. 549. -^O` w ral )vim JOB ADDRESS. AND LOCATION-------�--- ---------------- -�-----��- - ------- �►- - - ,� ---•--'- -- Owner's Name---------- 1V10AD_---A -� -- ------------------------------------- ----------- --- P oonnee..................... '.... --- i� 1 n Contractor's Name-------------------------------•--------------------------------------------------------------------------------------------...------- ------ Phone ...... ................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ , Motel 0 'Other ❑ Number of living units: ---1--- Number of bedrooms__-_ Number of baths _.1". Lot size ........................... Water SuPPI • Publics stem El Community system Private De th to Water TabIxft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam® Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No R New Construction: Yes)KL_ 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: Distance from nearest well ------ Distan a from fo ationo---_•-_--___.:Material�'e-nGy' .� No. of compartments-_---y'_-------------Size._ X3 _-_Liquid depth--- �-.-_._-_. Capacity.... _...__. Disposal Field: Distance from nearest well-P/ __Distance from foundation-=-/ .-_-Distance to nearest lot ine..i� ..... p « Number of lines.......%----------.. Length of each line.... !�--.___ .___.Width of trench.._•«' ...-..�_----. _-.- Type of filter material...c�;"Depth of filter material----I-r--_--.....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.....................---------- El -._-. -------❑ Size: Diameter—------------------------------------Depth----------------------------------------------------Liquid Capacity-----•-•--•---•-•---•---•.gals, Privy: Distance from nearest well----------------------------------------_-._---Distance from nearest building__-- _.------------------- Distance .._-_______---__-..------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. �"1(t� -------------------------------------------------- -----(Owner and/or Contractor) ••. . . - (Signed) By:---- --- --•• . --•-• ••-•-- ---•--. --••---•-•(Title). •--• •----•---...••• ---- ----------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). TME USE Y APPLICATION ACCEPTED BY a ----- - ---------- - --- - DATE..... _ REVIEWEDBY................----------------------------------------------------------------------- ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------•- DATE------•-------------- -------------•----------- Alterationsand/or recommendations:- -------------------------------------------------------------------- ........................................................... ----------•-------•--------•---•---•---------------------------------------------------------••----------------_--------------------------•-----------------•---------•--•---------•---------------••--_.•.......-------_ --- --------------------------------I------------- ---------------------- -'-�--------- ------- ---- ----- ------...---------- ----- - -- --.-- FINAL INSPECTION BY:----- - 1' - ---- Date. ��f.�. - a� - 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.