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APPLICATION FOR SANITATION PERMIT Permit No. A.. (Complete in Duplicate) �f 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION ------ --"---__4'_---_-----�`TV------------Y_h<C_„---- Nn -----•---------------- Owner's Name ------ Ak- i 4 Contractor's Name (ac '------------------------------------------------ -- Phone ----•---•-------------------------- y `r Installation will serve: Residence �x Apartment House ❑ Commercial ❑ Trailer „Court ❑ Motel ❑ Other ❑ Number of living units: I ------- Number of bedrooms __cZ Number of baths __j____ Lot size Water Supply: Public system ❑ Community system ❑ Private) `Depth to Water Table _-V ft. - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loem Clay Loam ❑ Clay ❑ Adob&A Hardpan ❑ Previous Application Made: Yes ❑ No $k New Construction: Yes ❑ No,KFHA/VA. Yes ❑ No LK TYPE OF INSTALLATION AND SPECIFICATIONS: { (No septic tank or` cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________ Distance from foundation ------------------- Material _______________.._.___________________.__.____.. ❑ No. of compartments --------------- ----- --- Size -------•------------I-------- Liquid, depth":--= ------------- ----Capacity- ------------------- Disposal Field: Distance from nearest well --- -------------- Distance from foundation -------------------- Distance to nearest lot line _______-._______ ❑ Number of lines ---•------------------------------- Length of each line ----------------------------- -Width of french --------------------- -------------- Type of filter material ------------------------- Depth of filter material ----------------------- Total length ------------------------------------------ Seepage Pit: Distance .to nearest well ---------------------- Distance from foundation ------------- ._.___.Distance to nearest lot line ______.______.__ ❑ Number of pits ---------------------- Lining material ----------------I ---- Size: Diameter ------------------------ Depth ----:-----.---------------------- Cesspool: Disfiance from nearest well t rQ_-Distance from foundation,01'._._.____.Lining material___/1L�9F&___. Size: Diameter_J__ '0-- ?__Z -----5 ---- Depth ----------- -ter---�----------------Liquid Capacity-- -IS-0-0 --- ;--gals. Privy: -Distance .from nearest well ------- __- -.-------T___" _Distance from nearest building__________________________________________ ❑ Distance to nearest. lot line — ------------------------------------------------------------------------------- -- Remodeling and/or repairing (describe): ------------------------------------- ------------------------------------- c -----------------------------------------------------------------------------------------------------------•---------------------------------------------------------------•------- ---- • ----------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law`s,-ani# rules and regulations of the San Joaquin Local Health District. t (Signed)----------- _ ------- t # + h ♦ i 3 t o ' : -=---------------(Owner and/or Contractorl .-- z - Title (Plot plan, showing size of lot, location of system in reration to wells, buildings, etc., can be placed on reverse side). S FOR DEPARTMENT USE ONLY.4, APPLICATION ACCEPTED BY = T -L •---- ----------•------------------- DATE , - . REVlEWE� BY ----------------------- - DATE BUILDING PERMIT ISSUED ----------------------------- ---------------------------------------------- DATE Alterations and/or, recommendations:---------------------------------------------------------------------•-------•---------------------------- ----------------t-------- -------- ------ =*4 `` --------------------------------------------- ----------------- --------- --------- -- --------------- - ------------------------------------ I r1 - �x>. r, ------------------------------=-------- :; W'1 , ----------------- ---- ---- -- FINAL e 1 1 t Ile _ YX� INSPECTION BY:.�. f --------- i Date -------- -� �t , SAN JOAQUIN LOCAL HEALTH DISTRICT ,tr 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. W 04