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2 APPLICATION FOR SANITATION PERMIT Permit No. _.��............... �� (Complete in Duplicate) (� Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinan o. 549. JOB ADDRESS AN LOCATIO ...______________ __ _______-_______ _ _ �y 2 Owner's Name------ ......��-- • ---------- Phone-----------•-•------------ Address.......... --------------------------------------------------------------------------------- Contractor's Name-OQ* _r --------------------------------------------------------------------------------------------------- Phone..........................-------- Installation will serve: Residence �A�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ II Number of living units: _I_..__ N er of bedrooms _,3_ Number of bath i________ Lot sizeO_ _ �©_____________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay E] Adobe ardpan C]Previous Application Made: Yes F] No New Construction: Yes o ❑ FHA/VA: Yes ❑ No Q� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic T Distance from nearest well__k _Distance from`ounda ion___/----------___.Materi I___Pei_-____________________ _ No. of compartments____2.------------- _. S_-�' .___Liquid depth____Y-__________Capacity.__.___ __ Dis osal field: Distance from neare t wellA/4'A.�-_Distance from foundation__/ _ Distance to nearest lot hiine_.�___.- _ P Number of lines___ __ _Length of each line_____ _. __:__ __ --_ sL�__f___ Width of trench__, _ Type of filter material___ d'GI-,______Depth of filter material------1- ---------Total length__OZ3;:::v ________________________ 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--------------------------_--_______. ❑ Size: Diameter---------------------------- ---------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------.__-______-_. ❑ Distance to nearest lot line------------------------------------------------------------------------------------•--------------------------------------------------------- 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 rules and regulations ,the San Joaquin Local Health District. XSigned)._4fA_A. ----------------------------------------------------------------- -----------(Owner and/or Contractor) By: Title-------------------------------------------------------------- Y (rifle) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------•---k4l ----- -------------------------------------------------------------- DATE................... REVIEWEDBY-------------------------------------- -- - -------------------------------------------------------------- DATE------ ----- -------------------- BUILDINGPERMIT ISSUED------------------ -- -- ----------------------------------------------------------- DATE---�--------------------------------------------- Alterations and/or re omm ndafiions:_- ----------------------------------------------------------------------------------------------------------------- l o - ------- - - - �� ------ ----------------- -- -------- t 1 ---- r" - ------------- --------- ----------------- ---- ---- = -1------------------------------ -------------- --- -------------- -------------------------- q FINAL INSPECTIODate � -------------------- ---------------- �SAN JOAQUIN LOCAL HEALTH DISTRICT / 130 South American Street 100 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.