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nw\k` ./ s . ^)/1X APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date 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 Cou nty Or nce N�549.JOB ADDRESS AND OCATION---• --- - •--- ----------•--------------------------------------------------------------------------- Owner's Name--------- ------ - ----•----------------------------------------------------------------------- ------------- Phone----------------------------------- Address--------- ( a Contractor's Name ---- ^' -�- ----------------------------------------------- - ------------ Phone----------------------------------- Installation will serve: Residence �artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms --)---Number of baths _/_ Lot size --_ ------ ---------_---___________________ Water Supply: Public system ❑ Community system ❑ Private O--Oepth to Water Table'ySft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe El---H�ardpan ❑ Previous Application Made: Yes ❑ No [P�New Construction: Yes ❑ No [R'*�'FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well_________________Distance from foundation--------------------Material-_-______________-.___________-,-----_________- No. of compartments--------------------- --Size-------------------------------Liquid depth--------------------------Capacity-------------------;-- F ( t qli,cTanil" posalFd: Distance from nearest well___?!)___._Distance from founda#ion_-J47a.s--Distance to nearest lot line__ `_1__ vV []� Number of lines---------- ___ ____Length of each line-----------c3 A Width of trench ----------------- Type of filter material___ i__ Depth of filter material--------,4f-'/__Total length.__-- er_____________--------------- Seepage ___________Seepage Pit: Distance to nearest well__10s-'--.--____Distance om undation-,fJ0_.._______.Distance to nearest lot line____�4_.--- _._.____Linin material----_ __._ -Size: Diameter___,3 -.`-" ' —� Number of pits--- � - g - -- --------Deptn-----.�J --- ----------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material_________.________.___------___.____-- ❑ Size: Diameter--------------------------------------Depth------------------------------------------------- -Liquid Capacity----------------------------gals. �Y Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lo# line---------------------- ----- --------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------------------- ---------------•--------------------•--------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- I ------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------•---------------------------------------------- I hereby certify thaf_ have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laks, an ules and regulations of the San Joaquin Local Health District. (Signed)---------------------------- ---f '� 'rF" - ---- ----- ---------------------------------------------------------- Owner and/or Contractor BY: -- ---------------------------- (Title) (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------ ------------- ------------------------------------= ----------- DATE------ j�` REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE----------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recomme dations:___ --------------------------------------------na---------�? ----------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- ------------------------- ----------------------------------------- F � ------------ -------------------------------------------------------------------------------- FINAL INSPECT] 7Z - ------ Date...... 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 , Rev:sea 1.57 F.P.CO.