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v -u7 s - . APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate)F Date issued V_Z 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 No. 54 . JOB ADDRESS AND LOCATION-------- Owner's Name---- 4 .4 .1 --- --------------------------- PhonaAddress_--------� -- � � ------------------------------ -•----- ---------------•---------- --------- ---------- - -•-•------- ' Contractor's Name-___. � �.- •-- - - --------- ----------------- --- ---------------- Phone - --------------------- -- nstallation will serve: Residence 23'-Apartment House ❑ Commercial a ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. __f-- Number of bedrooms _Z, ! Number of baths _____-l Lot size _ _ ___? Water Supply: Publics stem -- r Y ❑ Commun'ity system ❑ Private [I Depth to Water Table Character of soil to a depth of 3 feet: Sand ElGravel E] Sandy Loam ❑ Clay Loam [-] Clay ❑ Adobe( '`"Wardpan ❑ Previous Application Made: Yes ❑ No P`New Construction: YesNo TYPE OF INSTALLATION AND SPECIFICATIONS: ❑ �'FHA/VA: Yes El No -- i (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) eptic ank: Distance from nearest well----------------- Distance from foundafiion__________________Material___-__.___--______- �/7t �� No. of compartments-------:--- --------------------------- ' ` ---------Size------------=--- - ---=---Liquid clepth_.-------------- ---------Capacity-------------------- Disp sal Field; Distance from nearest well-----------------Distance from foundation-------------------_Distance to nearest lot line.___.,_____ n ` ; Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------_---- Type of filter material__-_ --- - ---- - ------Depth of filter material--------- ------- -----Total length-------------------------------•----•-----r Seepage Pit: Distance to nearest well-__,t� -� Distance from foundation_____._____ / Distance to nearest lot line _--• -___- Number of pits:----/.-------- ---Lining material �-- 1-----Size: Diameter----• S-f�------pepth . _: _', r tn esspool: Distance from nearest welt_________________Distance from foundation-------------------- material--------------------------- El Size; Diameter--------------------------------------- Depth------ -- --•-- ------------------------- -----------Liquid Capacity_.-,------------------------9afs.0 . Privy: Distance from nearest wEll_____________________ --_________ _Distance from nearest building g ------------------------- El ---------------- Remodelin and or repairing -------------- / ��°-------- ------ --------- --- •--------------------J--- Distance o nearest ofi line tf ---------------------- ---- -----•--------------------- --•--•--•---- --•-------------------•---------------- ---------------- -------------------------------------•-------------------------------- --------------••-------------------------•------------------- - - j '' 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 reguiatione%f_the San Joaquin Local Health District. /' fes/ I /: - f /- --------------------------------------------------------------- By:. ------------------•------- - f-- - l <=/ Contractor) ------- ) or G or (Plot pian, showing size of lot, location of system in.relation to wells, buildings, etc., can be l placed ?reverse se side-- } FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.__. -_ -._ - __"______ REVIEWED BY DATE cS ---------------------- ---------------------=------------- - -- ------------------ DATE----------------------------- BUILDING PERMIT ISSUED ----- --- -------- ------------------ -----------DATE--------------------- Alterations and/or retornmendations------------------------- -----�-------------------------- - --- ---------------Z---- ----------------------- - =:rte: --- - -------- - ------ -_----------.-----.----------------------------- -- •------- - - --------------------- -------------------------------- ---- FINAL INSPECTION BY--c ----------- ; -- -` _ ---------- "------------ -Date-- "-j _�..-- - ------------- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT !30 South American Street �- i 300 Wes} Oak Street f 32 Sycamore Sfree} 814 North "C" Street Stockton, California Lodi, California .. ' Manteca, California ' • Tracy, California ES-9-2M . Revised 1.67 F.P.CO:•