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f" APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ____� j�_- 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 549, JOB ADDRESS AND LO TION _ -b----/-------------- --------------------------- ----------------- irk Owner's Na ________ _-� ----- - t ------------- ---_ Phone----- -- Address --------- ---- --- Contractor's Name _.- ---------------------------------------------------------- Phon - --------- Installation will serve: Residence9[ partmerit House❑' Commercial[] Trailer Court ❑ Potel ❑ Other ❑ Number of living units: ` __ �_ Number of bedrooms �_ Number of baths _�_ Lot size ___ ___G?_X/,�l7--�.___ _________________ Water Supply: Public system ❑ ommunity system ❑ Private Depth to Water Table 7--4 ft. Character of soil to a depth of 3 `eet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam ❑ -Clay E] Adobe �ardpan ❑ Previous Application Made: Yes d No 12___'New Construction: Yes ❑ No [] FHA/VA: Yes ❑ No ❑ E TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) 1I ! #1n, Distance from; nearest well___________'Distance from foundation_____________ Material No. of compartments------ ------ ------------Size`----•-------------------------Liquid depth--------------------------Capacity...-------------------- : Distance frominearest wefi_________________Distance from foundation___-.-__-----____._.Distance to nearest lot line____________--__- .Number of Tines ______ Length of each line______________________________Width of trench__________-----_--_______________- Type of filte+r material__________________t__Depth of filter material_____ --- length___-_--_-__________________________--___ i See a e •t: Distance to neaiest well/�r'Q___.___ Distan om oundatio __ p p g ___.___._..Distance to nearest lot line_____a________ Number of piks_� Lining material_ _ °r_.__.Size: Diameter___ _a2��_ Depth �� / ---- p . -------------- Cesspool: Distance from nearest well_________________Distance from foundation ________.Lining material------------------------------------- 0 Size: Diameter---------------------- ------.� Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------- ------------------------------Distance from nearest building_________.___--------________.__________- ❑ Distance to nearest lot line-----------=�----- ----= gand/or repairing (describe): _ _ _ __________________________________________________________________________________________________________________________________________________________________________________________________________________ ! hereby erte that I hay prepare this application and that +he work will be done in accordance with San Joaquin County ordinances, S ate a s, and le and're atioris of +he San Joaqui oval Health Distric+. I (Signed)- -------- ----------- --- -- ---- - -'------------------------ wrier arrraar{ ( s {Title) '�Y --------------•------ -------- ----- --------- ------ -------- --- (Plot plan, showing size of of, location of system in r on to wells, buildings, etc., can be placed on reverse side). FOR PARTMENT USE ONLY APPLICATION ACCEPTED BY. DATE ---------------------------------------------------- \ REVIEWEDBY------------------------------ ---------------------------------------------------------------------------- DATE-- BUILDING PERMIT ISSUED--------- -------------------•------•------------------------------------------------------ DATE-- -----------------C� ----------- ------------ -------------- Alterations and/or recommendations:- .------------------------------------ ------------------------ ----- --•-----------------------------------•----------- -------- --- --------------------------------------x•------------- --- =�, - ------ - -- - -----------------•-• ----------------- ---------------------------------------- -------------------------------------------------- --- -- -----------•-----------------------•------•------------------------------------------ - -------- -------•--------- -------- ------------ -- - ---- - ----------------------------- -------------------------------------------------------------------- FINAL INSPECTION BY___________ ___ ------- ------- --- ---------- Date---------- SAN ------ --SAN JOAQUIN LOCAL HEALTH DISTRICT r 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 � Rev'ssea 1.57 F-RCO.