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1 APPLICATION FOR SANITATION PERMIT Permit No. .---`.'---- Z . (Complete in Duplicate) --` pate Issued .-"_.""_""�ya/.:5_�. 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 compiiance`with County Ordinance o. 549. JOB ADDRESS D LOCAT K- - -- ---- ------- ---------------- -- -- ----JT-------------- Owner's Name- "r-- j `'e ---------------------------------"----------------- ------ T;-------- Phone---- „• - - ------- Address --•-- Address-------------------- = Contractor's Name--------- :. --•------------------------------- ---•----- Phone Installation will serve: Resident Apartment Nouse ❑ Commercial ❑ Trailer Gour# ❑ tel ❑ JOther ❑ Number of living units: _�____ Number of bedrooms 2'." Number of baths -------- Lot size _-__�__---�-__----)I _""""_"--:.-..-._"___ Water Supply:. Public system Com,ffiu'nity system ❑' Private ❑• Depth to Water Table ----- '"ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 21-* Hardpan ❑ Previous Application Made: Yes ❑ No New Construction' Yes No ❑ FHA/VA: Yes ❑ No m TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within.200 feet.) ` Y -. Septic Tank: Distance from nearest well___"";-_"_______ -Distance from foundation------------------ Material-------------------------_-------------------_-_-_-_. No. of compartments— _ __________ _____ Size------••-------"- ---"""-___-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 weEl-.- ____-"_-_--_-__Distance fromfouridation_------- __:_..Distance to nearest lot'line------ ---------- ❑ Number of pits----------------------�Lining -material------------------------Size: Diametiyr Dep ----------- I ------------------- n p _"" "_ e from„foundation-/=.!_.___.Lining material_"-- t Ce sol: Distance from e est well-pY "Distanc $f Size: Diameter - -". Depth -- ------------------------------------ Liquid Capacity �� ------;---gals. . Privy: Distance from nearest'we1L_________."-"-- ------------Distance from nearest building_._____""_"""--.-"-"__________________". "11 ❑ ----•-------- Distance to nearest Iot�Gne.-=------------=�__-'_ =-"` -- � - - _ ".� - _.�` �. 9 :. Remodefin and/or repairing (describe--------- --------------------- ----•-•----------------•-------------••-•-�----------------•-------------------••-•-•-"--•--•----• • ----'--•------.. --------•- •----------......------ -----------•..........-------------------•--- ---------=-------------------------- ' --•-------------------= ----- -------------------------------------------------------------------- ----------------------------•-----------------. ------•------•--•----------- I hereby certify that l have prepared this application and that the work will te done in accordance with San Joaquin County ordinances, ate laws, and rules and regul tions of the San Joaquin Local Health District. A . t (Signed} ------ (Owner and/or Contractor) ------- ----- By:_ --- 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-------------------------M----- u-- - • ----- ----------------•-•------------- DATE----------••------ --------' _ REVIEWED BY-------------------------------- ------ ------------------------- DATE BUILDING PERMIT ISSUED"_------------ - --—- ----------------=-----------=----------------------------------------- DATE----- ---- - ----------------------------- Alterations and/or recommendations:---.-- -- ----------------- ---=- -----------------_-----=-----------TU - - • -- ----------------------------------•-- -•-----" "----- --------------------------------------------------- --- ----------------------- --- - --- ---------------- -----•----------------------- -------•-• ----------------- FINAL INSPECTION BY:. = ------- ,� = _ pate-=- Ci- 1-------•-----^-~- SAN JOAQUIN LOCAL,HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.P.CO.