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„�� GJ / r3� elf APPLICATION FOR SANITATION PERMIT �,` � Permit No. ._ (Complete in Duplicate) I ” 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 CATION_--` -r* " �. ' ---- ----- Owner's Name------ -------------- ---------------------------------------------- Phone------ ----------------------------- ------ ---------------- Address-----•---- ---------------- Contractor's Name------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1___ Number of bedrooms S- Number of baths/i.: Lot size --- G' f'----------- Water Supply: Public system ❑ Community system ❑ Private [,Depth to Water Table IWITt. 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑' Na P�r New Construction: Yes [kr No ElFHA/VA: Yes [kj No ElPrevious Application Made: Yes F1 TYPE OF INSTALLATION AND SPECIFICATIONS: op (No septic tank or°cesspool permitted if public sewer is available within 200 feet.) �� Materiel J_ Septic Tank: Distance from nearest well___ P_-. Distance fr r� founda� n________ ____ / _ No. of compartments_----: --------------Size___ - - 1 __Liquid depth_----- - - Capacity--- -- ------ -J ' � - r I�1 Disposal Field: Distance from nearest well_410.......Distance from foundation_,-{_O&..-_-__.Distance to nearest lot line----�-__- } ool Number of lines------- ------ ---- ------�--Length of each line------ v __-----f`-----.Width of trench----ee --------------------- Type of filter material--/-_ j/GDepth of filter material--_-/01?.............Total length___.-_ _____________ y._�_ ., Seep Pit: Distance to nearest weld____=��----_-Dsstance fr9m foun tion__.__. ----..Dis ante to nearest to line�_m Lf7 1''QoI Depth ___ ._ c Number of pits----- -------- -----Lining material-/-17-0 __-_Size: Diameter_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- ❑ Si ---------Depth----------------------------------------------------Liquid Capacity--------------------------gals Size: Diameter--------------------------- - Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------------------. ❑ Distance to nearest lot line-------------- --- - --------------------------------------------- ------------------------------------ ` Remodeling and repairing (describe):___._. ----------------------------------- �i" � ------------------------------------ --------------------- -•------------------------•--------•----------------------------=-•---------------------------------------------------------- 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 reg lations of the San Joaquin Local Health District. or Si nedV,44�1 '� ------------------------ ct ( i9 ]---------- r Contra or]f --------- ------ (Title) --: By:--------------------- - �'`- (Plot plan, showing si # lot, location of system in.relation to wells, buildings, etc., can be plat on reverse e]. i FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------ --- -- ------------------I----------------•----------------------- DATE------ ------------------- ------------ REVIEWED BY-------- DATE--------------------- --------------------------------------------------------------------- DATE-------------- - BUILDINGPERMIT ISSUED------------- -- --- ------- -- ------------------------------------------------------------- d Alterations and/or recommendations:----- --- _ ---- -----------•- ---------------------- -------------------------- -•-------------------------------- ----------------------------------------------•---- ----� �" c. ......�" � {_ ------ •.P�e_ �. _ . -------------------------- -------- ---- --- --------------------------------------------------- ---•------------------- ------------------------------------------- --- -------------------------------------- ----------------------------- -----------------------------------------------F------------- ------ FINAL INSPECTION BY----- ----- ---•----- -- - ---- Date---- =j_.___✓I./ ' ------- --------------------- 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 t ES-9-2M Revised 1.57 F.P.CO. e r �1