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Permit n APPLICATION FOR SANITATION PERMIT r ,> (Complete in Duplicate) Date Issued -" � l - Application is h by made to the San Joaquin Local Health District for'a permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. 549. � � �- ------------------------- JOB ADDRESS AND LOCATION---------------- � �------------ ---- Owner's Name-------------------•-------- F1 f_7�-----•----•-- Phone Address----•-------------- ----------------------------------•------------ Contractor's Name----------------------•----------•------------------------- --------- - •------------------•------ ------ Phone----------------------------------- ; Installation will serve: Residence Apartment House F1 Commercial ❑ Trailer Court [I Motel [I Other E] ,Number of living units: ______._ Number of bedrooms ----I--- Number of baths ________ Lot size -------- ----------- Wafer, Supply: Public sys#em Community system ❑ Private 7 Depth to Water Table __:� ft. k Ir Character of,`soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam El Clay Loam El Clay ❑ Adobe Hardpa�j}.❑ I ' . Previous Application Made: Yes ❑ NoNew Construction: Yes No ❑ b TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet:) I_ m �--.-Material____._______________._____-_____.___.______.__. Septic Tank: -%Distance fromnearest well________.-_____ sance ______ ----------------------Capacity----------------------• Nomof compatments..-----.- -.- - Size ---- ----- Liquid de •th l Q r Disposal Field: Distance from nearest.wel ,5.Q_ .__Distance from foundaa"tion_____40_______- Distance to nearest lot li e____S_.__.__. Numbervoirlines------------i--- -'---------------Length_cLf each line°--:-------6-0-------------.Width of trench Type of filter,mates-ial� .11-Y9 '1Dept� o filt malarial-------�dr��--------Total length---------6Q-------'--------------- '• Seepage Pit: Distance to neaest�:welL.___________________Distance from founda#ion_______..____.____.Distance to nearest lot line--------------- F1Number of pits._`s----------------Lining m ferial_--- Size: Diameter Deptn ,.+ ,arbst well__________.____:Distance m from foundation.._._____________ Linq rna#erial--------------------______.__._.----- Cesspool: Distance from:ne -- _"i Li uid Capacity ---------gals.O Size Distance Deefrom I .1. . Distance from nearest building----'-----------------------------'------- Privy: 3 nearest well --------- ------- r , ,..�..,�y .ws.....�.Via.. -�..�.wr- -, ... --•----- ----------------------------------------------------------------- ----------------------------------------- ❑ Distance to nearestlot'ine__"______-___________ - s Rernodeiing rand/or repairing (describe):---------------------------- l «•--------- -• --- - -- --------- -----------------------•-------- o � -i --------------------------------------------------------1 - ! t I hereby certify that I h`ave prepared this application and that the work will be done�sin accordance with San Joaquin County ordinances, State laws, and fu l s and regulations of t e San Joaquin Local Health District. I ----------------------------------------------------- ----------------------(Owner and/or Contractor) (signed)_ - -- --- ------- -- - Tit e (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side)..- i FOR DEPARTMENT USE ONLY TDATE - APPLICATION ACCEPTED BY____-__.""_-------'------- - -- - - ------ ---------- ----- ---------- - ---------------- REVIEWED = BY------------------- 3 z tir" > ' ' RATE:_ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------ Alterations and/or recommendations:__-____._------------- ------------------------- --- ---- ----------------------------------------------- -------- -------------------------- -------------------------•-------f-------------- ----------- FINAL INSPECTION BY----------------- ---• - ------ --------- ---- Date " ' -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 sycamore Street $14 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California Y ES-9-2M 0-52 Revised W-2100