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APPLICATION FOR SANITATION PERMIT Permit No. _.__ .. �. _...- �, I` o (Complete in Duplicate) It. L. 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_____-_ ----------------. Owner's Name------------------------------------ -- �. lt :dCG+rC� Phone. Address .... ._. ._ _._.. _�' -------------••---------- --•- Contractor's Name--------t - . .!- 't --------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence,' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___J__- Number of bedrooms __Number of baths Lot size ----------______________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ON Hardpan ❑ Previous Application Made: Yes ❑ No)Q1 New Construction: Yes g No ❑ FHA/VA: Yes ❑ NoN;< TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) is Distance from nearest well_________________Distance from foundation-------------------.Material------------------------------------------------- No. of compartments--------------------------Size------------------------•-------Liquid depth--------------------------Capacity..--•----------------- Disposal Field: Distance from nearest wellAA&m..t,_Distance from foundation---LL2__________-Distance to nearest lot line_____S_-__.__. Number of lines------------_--- ngth of each line-----_C,._6-----------------Width of trench-_-- a-4- ---_----------_--.-- `� Total length 14----------------------- Type of filter material ____ f filter material_._�__�______- g )_ Seepage Pit: Distance to nearest -ell----------------------Distance from foundation--------------------Distance to nearest lot line._______-________ ❑ Number of pits----------------------Lining material-----------------:------Size: Diameter_--------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- F1 Size: Diameter------------------ -------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well___-----------------------------------------------Distance from nearest building----------._________________________--___. ❑ Distance to nearest lot line----------- --------------------------------------•--------------------------•--------------•----------•----------------•----------------------- RemodeiinWd/or re iring clescribe):--�Gt' ---_- --_��C�.�•c. � ------�z�i_•�_ 4_•...- Vit'-----•............. �� .rG�------------. �-�� ---•------------------------------ -- -- ----•------------------- ----------------------- ------------------------------------------------------------------------------•------------------•---•--------------------------•-----------------------•---------------••--------------•- ------------ 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 regulations of the San Joaquin Local Health District. (signed} -4�- ,-•p�` b------ ,�F�_rr'---4 "--- ----- -----------------(Owner and/or Contractor) --- - -------------------------- ------ By:.....--.0; O, ` - '' ------------------------------------------------(Tif le)------------------------------------- (Plot plan, showing size of lot, location of system iti rel ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- ----------------- ------------------•----•-•------------- DATE------ -----------------------••--------------------- REVIEWEDBY------------------------------------------------------- -------- ------------- -----------------------------------------. DATE BUILDING PERMIT ISSUED ----- DATE-- --------- ------- -e----------------------. - -- Alterations and/or recommendations:----------------------- ----------- -`-----•-------------------------------------------------------------- -- --- --- - FINAL INSPECTION BY:------- --------------------------- Date_- = .y'~a� lr ---- 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.