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Am APPLICATION FOR SANITATION PERMIT Permit No. ----- ------------ (Complete in Duplicate) ✓� Date Issued ---. .�tAi_ A lication is here made to the San Joaquin Local Health District for ermit to con truct and install the work herein described. pP ,, Y q P This application is made in compliance with County Ordina ce No. 549. �s -----` -- --------- --------------• -------------•-----•--•-------------•---•--------.... JOB ADDRESS AND LOCATION...../..�� ... .... ...................._-.- - Owner's Name----�f-�-�-'--- - Phone --------------- Address e�► ' ----------------------------------------------------------------- ----------------------- -- --- --------- --------------------- - - Contractor's Name i'__--- - Phone... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:-t--. Number of bedrooms -_ - Number of baths -%I-- Lot size -. - [ '------------------------------ Wafer ----------------- -Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table F.2--ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 13" New.Construction: Yes ❑ No 8'FHA/VA: Yes ❑ No RE-' 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.fours ation_-- d IP---------Material---&------ .--,--t-- - ---------------- �� No. of compartments.._ ,------------- ..X ....._Liquid depth... .. 'L / Capacity... ''.�_�.___ �, Disposal Field: Distance from nearest well----'. _+____.Distance from foundartion-!1-1-o.......-3istance to nearest loft line._�'�. Number of lines.:..__.___ . a ength of each line.n4_�.../,0__,�_.Width of trench.A .,.�.... ..... ..... Type of filter material. p ....___.__-Total length___!_ �__. e th of filter material _ Seepage Pit: Distance to nearest well______a-- ---.--Distance from fou ation-_ 9® --__-.Distance to nearest lot liner_9--- -- Number of pits...... ... .. ....Lining material Size: Diameter._ ------ ...Depth----A-0---------- (� "V Cesspool• Distance from nearest well.................Distance from foundation--------------......Lining material-------------------------------------- ❑ Size: Diameter-------------------------------------Depth--------- --------------_---- ---------------------Liquid Capacity----------------------------gals. Privy: '-Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot line--------'-------------------- •---- PAZ/ Remodeling nd/or repo'ring (describe}:--- ---- - ---- --- -------- __--•-_ � --- - --.. ! ------------- -_.�_`_ _ ._._.. •1' :i ----_ �_hey._.t~+. --.ftr- J_.�,.....................•_._-----__--.`s......._..-._...--_ lo I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law and rules a regulations of the San Jaa in Local Health District. (Signed) f° ------------------------------ -- - -----�J- ----- ------------------------------ ----------------------------------I Contractor) By:--------------------- ---------------------(Title)--- (Plot - 1 --- - - ------------------------------------------- (Piot plan, showing size o of. location of system in relation to wells, buildings, etc., can be placed on revers ide). r . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .� = BATE ------------- REVIEWED BY---------------------------------------------- --- - - DATE--------------- _' BUILDING PERMIT ISSUED.......................... .. _ DATE_. . __.. ._._.___ - - ---- --------------- --------------- ----------- Alterations and/or recommendations:-------- ---------------------------------------------- -------•--- ----------........... --- ---------....----------------------------------- -•----------------•--------------------------------- -----------------------------------------------------------------------------------------------•----------------••--•-----------------•-•---•----------------•----------- r ------ ------ ir 1 FINAL INSPECTION BY:. = ------------ Date;�+' d 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. f