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I APPLICATION F0A- SANITATION PERMIT Permit No. "" (Comple+e in Duplicate) ��f/1Jl / '� �/ ------------------ Q �; Date Issued/ '�" f � 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 AND,LOCATION._________ __" - -- Owner's Name---------- r /i • I - ----- -------------------------------------- Q .. _ .. - - -------------- --------- Phone_.-------- -----------��- Address__..-__-"-- .•- � t ... i . . ..+ ------------------------------- Contractor's Name----=----•--•-- ---•--------------------•------------•------ - ---- Phone----- ------------- Installation will serve: Residence• Apartment House ❑ Commercial [I Trailer Court ❑ Motel D Other ❑ Number of living units: -------- Number_,of bedrooms ----- Number of baths _.------ Lot size Water Supply: Y � ----------=----- ---- ---- ppy: "Publicstem ❑ Cs ommunity system ❑ Private �epth to Water Table=--ft. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] Clay Loam ❑ Clay Previous Application Made: Yes El No [ El Adobe Hardpan ❑ ew Construction: Yes ❑ No FHA/VA: Yes ❑ No [� 7 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool per if public sewer is available within 200 feet.) ` Septic Tek: Distance from nearest well ®/ . ------ Distance Distance from foundation" �"_ ___.Material ,No. of compartmens-'-------- . Size_� .x S'.A_1- Liquid depth -- ---- --= C'ai�acityz Q_ Dispose! Field: Distance from nearest well---" -_1 Distance from foundation__- _d,_c_ ❑ Number of lines _ ':_ - "_._.Distance to nearest lot line "_"".""_ = -----".Width of trench Length of each line_______-� Type of filter material_4&`zl------" p p k De th of filter material__=_ --_-------Total length ._�------_--" Seepage Pit:.- Distance to nearest'weii_ :_-:-- _Distance from foundation___ o " ;Q"_ _.ce,to nearest lot line-471,f . Number of pits------__/_"r_--""__"Lining ma#erial__ _ +�'" Size: Diameter. -," Tr�Depth ._. Cesspool: Distance from reaEl Irestrwell_°:____"-__----."_Distance from foundation__-,_--- -""_-_" ,Linin I g.material ---- ;- -------------- --- --------------------------------Diameter-----` -=--------=------ ---------- Depth=------- ----------- •---------------------------- - ., '� w, � � - Liquid Capacity ---------------------------gals. Privy_ Distance from nearest well_______________t "-,- : ------------ from nearest buildin f ❑ Distance-to nearest lot line - g -------------•------- ---- r w Remodeling and/or repairing (describe :___-_ __ __ _ f ] �? . '. � - s __.______,._________- a __"""______________________________.__------- ______--"_--____-__--___.--____ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinance$, State'I ws, and rules and regulations of the San4 Joaquin Local Health District. (Signed)- I iP BY------- --- - - +._(Owner and/or Contractor] ___________ (Plat plan, showing size of lot, location --- ----------(Title)-.----------------of system in relation #o wells, buildings, etc., can be placed on reverse side). i ` FOR -DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------3 ""_ "__ - .. --------------------------------------- I REVIEWED E BUILDI --`-------------------------------------------- -------------------- ------------------ DATE------------------------------------.. -------- Alterations and or recommendations. ----------- --------- ----------------------------------------------------------------------- BATE .. .^ ecommenda+ions:--- ------ - - _ •. --------------- -- ------ -------------•----•- ING PERMIT _ _ ---------------- ------------------------- ----------------- n c�_�--- ----------------- - AA --------------------- ----- FINAL INSPECTION BY:------- a ----------=----- ------ - Date__=......' - - -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stook+on, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.P,CO. 4