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APPLICATION FOR SANITATION / N PERMIT Permit No. ----T_X.j (Complete in Duplicate) Date Issued .___._tJ_- 1 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 Ord' ante No. 549. JOB ADDRESS AND LOCATION-- Owner's Name_____ ----------------------------------------------------------------------------- _________.____ --------------------------- --------------- Phone----------- Address--------------------------- ----- - Contractor's Name_--- ._ r + ------- - Phone -- - -------------------------------------------------- - nstallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms _1_____ Number of baths -1- Ile---_____ Lot size _ ____. Water Supply: Public system K Community system ❑ Private ❑ Depth to Water Table r.�_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay [I Adobe 9 Hardpan ❑ Previous Application Made: Yes El No T New Construction: Yes 4 No ElFHA/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-----------------Distance from foundation______ --------------------Material ---- -------------•------ - - n No. of compartments-------------------- ---Size---------------------------------Liquid depth_--------------------Capacity -- --------- Disposal Field: Distance from nearest well--------------_-Distance from foundation--------------------Distance to nearest lot line____ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of Type of filter material____ _ 1---_ Depth of filter material_________________ __Total length--- Seepage Pit: Distance to nearest well--- -----------Distance from foundation__ � �_____-Distance to nearest lot line___$-- ------- ----- Number of pits �___-__-_____--Lining material-_�,t_('_'�-_-_--Size: Diameter--- _ - —i l Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_____-_______________-__-_______ ❑ Size: Diameter--------------------------------------Depth-------------------------------------------------- Liquid Capacity ----------gals. Privy: Distance from nearest well_ _______________________________ ___ __ __ Distance from nearest buildin ❑ Distance to nearest lot line 9------------------------------------------ Remodeling and/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 I nd rule nd regulations of t e Sa oaquin Local Health District. (Signed)------------ _____-( caner and/or Contractor) BY:------ ------- (Title) - -_ - -- ---------------------------------------------- -- (Plot plan, showing size of lot, location o system n relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----_-_____�_- -------------------------------------------- DATE--------��= REVIEWED BYtL -------------------------------------------------------------- ----- DATE------------------------------------------------------- Alterations PERMIT ISSUED--------------------------------------------- ------------------------ ------ ------ D Alterations and/or rico mendations_ ____________ _ DATE f/7--•------L ; - -•------------------------------- . 6 Kry �. ` ------------ ---------------- ------------------ FINAL INSPECTI BY ----- . -- ''}t Date------ SAN --- /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.