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a APPLICATION FOR SANITATION PERMIT Permit No, .A 0__.,7.._. \U (Complete in Duplicate) t D,.�te Issued _-&_/ – 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 WLON_ __ --- --- ----- ------- --- ------------------ Owner's Name ------ --- -------------------- Phone ---------------------------- Address-------- ------------ �T t Contractor's Name.............................. - `------------ a-cl ------ -------------------------------- ----•-•---- --------- Phonee---.z,e --� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ,0 Other ❑ Number of living units: _�__.__ Number of bedrooms ____2-..Number of`baths ---/-- Lot size -----------:5 .............. Water Supply: Public system D-1fommunity system ❑ Private ❑ Depth to Water Table ,7ft. , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe Cjpi`airdpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ 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- o Distance from nearest well_________________Distance from foundation--------------------Material---------------.__.___-__--__---____________•___- No. of compartments------- ------Size-----------------------•---=---Liquid depth--------------------------Capacity------------•-------•-- Disposal Fi Distance from nearest well----- Distance from foundation.._.e�r----------Distance to nearest lot line---/4-7_."'. Number of lines.__________�_________________f Length of each line------ AV—............Width of trench-----�1f__"____.____________ �- Type of filter material.__/� Depth of filter material.f•X��---------Total length---------AP---..______-_ Seepage P' . Distance to nearest __________-_Distance from foundationDistance to nearest lot line__4-__-__-__ Number of pits_______,__- -- ---Lining material_Y"Ot_4-_______-Size: Diameter_---��-7__.___Depth_- -_�_____"__________ �. ; 41�'_, Ces _. Distance from nearest well-------------- from foundation--------------------Lining material-------------------------------------- ❑ Size: Diameter-------------------------, -------Depth----------------------------------------------------Liquid Capacity----------------------------gals. (� Privy: Distance from nearest well------------------------------------------------- from nearest building �j ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------•----------------------------------- • � c7• a -� 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 laws, and /v d regul ' s of the San Joaquin Local Health Di, cf. --- d-------_----- - -- - - ----- ------------ --- 1-�t.--- -- ------- -------(Owner and/or Contractor) (Signed) By:---------------_-------- -- ---- ---- ---•- Title (Plot plan, showing si o lot, to tion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------- ------- -- pa, ---------------------•--------------------- DATE----------- REVIEWED BY-------------------------- __ DATE-__-_-- ------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations;_______________________ t -------------------------------------------------------------------------------- x- --- --- -- - ------------- --'� _ ______________________________________ _________I___________-__-__-_ __.-_____ -----------------.._--___---__._________. ____-___-_______-_____-_-.____-_-_______----------------------------.____--__-_ -.____•___ FINAL INSPECTION BY:----- ..... ------ ------------------- Date--- C 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.