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�1 t APPLICATION FOR SANITATION PERMIT PerTnit c� 1 Q �/ (Comp[ete in Duplicate} Dat sued _ 7- Application is hereby made to the San'Joaquin Local Health Di ict for a permit to construct and install the work herein described. This application is made in compliance with County Ordinanc o. 549. JOB ADDRESS AND LOCA ION______s e -------- ------- -- ----------------------------•------ ---- ---••----•-•-------------------- Owner's Name ,r = -- --- ----- Phone Address----------------------------------------------- -------- ------------• ------------------ - --------------------= --•---------------------- 1------------------------------ Contractor's Name--- --"v -- ----� -------------- '------------------ ------------------------•---- Phon . ....7 Installation will serve. Resi'denc`e Apartment House-E] Commercial ❑ Trailer-Court ❑ Motel ❑ Other ❑ Number of living units: __ _.__ Number of bedroom's—7_ Number of baths __/__ Lot size ___ a_.._____?�______�_ _______ Water Supply: Publicsystem Community system El Private El '-Depth to'Water Table. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ CIay'Loam ❑ . Clay ❑ Adobe <lardpan ❑ Previous Application Made. Yes ❑ No �w Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ��rr TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or`cesspool permitted if public sewer is available within 200 feet.) ! Se T Distance from nearest well_________________Distance from foundation________...___.____.Material_._--_..__________.____.____________.._._._____- No. of compartments-------------------------Size-------------------------------Liquid depth--------------------------Capacity----------------------- , Di I Fi Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line._-___-_-,_.___._ Number of lines-------- -------------------------Length of each line-----------------------------.Width of trench----------------------------------- Type of filter material_______________________Depth of filter material-___.-------------------Total length__--_-__.------____-___________________--- I Seepage Distance to nearest well-7 N __ Distant o foundati0n---.___0= ._..Distance to nearest lot line---X7 -__.._ Number of pits---- .------- Lining material---- ----- ----`_ ---Size: Diameter-- --- ---Depth__.Z -- Cesspool: Distance from nearest"well--------------- _Distance from foundation---------------------Lining material-------------------------------------- ( , W ❑ Size: Diameter-:----------- ----------------------t Depth------.-----------'--- -----------`-- --- l-----Liquid CapacitY-------------------------- gals.\ - Privy: Distance fromen arest well__:.______________________ ______________s_._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, 5t a laws, and rules and r ulations the San Joa uin Local Health District. I `_ ` �..` / '2� --( Contractor) (Signed)..-- �� - gY:----------------------------- --- --- ---- --------------------------------------------------(Title)- ------------- -------- --- ------'--- (Plot plan, showing size of lot, to ion of system in rel ion to wells, buildings, etc., can rye placed on reverse side' FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------- ---- -------------------------------------------------------- DATE------- -3----------------------------------------------- REVIEWEDBY----------------------------------------------------- ---- ------------------------------------------------------------- DATE----------- BUILDING PERMIT ISSUED----------------------------------- --------------------_------------------------------------- DATE--------------- Alterationsan5or r ommend tion ' _ _ - -----=---------------------------•--•--------------- - -------- ---------------- ------ --------------- ----------------------------------------------------- - -------- --- - ----•--------`-�-------------------- -------------------------- ---� / -----------I----------------------------------------------------------------------------------- ---------------------------------------- ----------------------------------------------------------------------------------- ----- -FINAL INSPECTION BY: 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 . Revised 1.57 F.P-CO.