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-A APPLICATION FOR SANITATION PERMIT Permit No. l# �� [__ _ Duplicate) -� u Compplete in D _ Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins+all the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCA ON-- !� --------- 1�a T ------------------------------ --0-------- -- ---- ---------------------------- Owner's Name ` <,--------------------------------------------------. '� `x` �� ------------=------------------------------------------------- Phone--- ----- 7 Address------------------------ / :Z. ' --------------------------------------------------------------------------------•------------------------ ---------------------------------------- - Contractor's Name-------------------------- ��` -------------------------------=-------------------------------- ---- Pho,ne-------• ------------••--------- Installation will serve: Residence M� Apartment House Commercial F] Trailer Court ❑ Motel E] Other ❑ gr l Cad �` ----------------------------------- Water =` Number of livin units: ________ Number of bedrooms _:__ Number of baths _____.__ Lot size _____.._"__ __ ________________________________ Water Supply: Public'�system X Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Grave! ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ No P5 New Construction: Yes yK No ❑ FHA/VA: Yes,®' No ❑ TYPE OF INSTALLATION WAND SPECIFICATIONS: p .esspool permitted if public sewer is available within 200 feet.) {No septic tank or'ch Distance from nearest well__ ---_�__Distance from foundation____/D_______-Material____( Septic Tank: Distant, p �---------Size__ _X_G "^_Liquid depth_______Y-_____________Capacity----------------------- Disposal ____._ ___. No_ of Ecom compartments __._._ Numoe,� of lines__________=_ . _______ Length of each line__________ �"--"""'Distance to nearest lot line_______ �--. Disposal Field: Distance from nearest �l----�!___.Distgance from foundation_____ �r Width of french_.____Z��______________ yp f filter material -- _Depth of filter material_______��________Total length__________________ __I------ Seepage ------- See a e Pit. Distant` e o l p g e to nacres -__ -------Distance from foundation--------------------Distance to nearest lot line_______._________ 1 E1 Number of pits----------------------Lining material--------------.--------Size: Diameter-----------------------Depth--------------------------------- ** t Cesspool: Distance from nearest well-----------------Distance from foundation.-----------------__Lining material-____________________- ______________. y Size: Diameter--------------------------------------Dept h----------------------------------------------------Liquid Capacity--- ---------------------gals. ❑ Priv e from nearest well._.___________________; ______________________Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line-------- ----------------------------------------•--------------------------=------------------------------- Remodeling and/or repairing (describe):------------------------------------- ---------•------...-------•----------••-----...--- - --- ---------------------------------------------------------- V, ----------•----------------------------- ---------------------------------------------------------------- --- ------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- ------- ------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- ! hereby certify that [have prepared this application and that the.work will be done in accordance with San Joaquin County r ordinances, Stataws, and rul s and regulations of the San Joaquin Local Health District. k (Signed) ----`-------- -------- ------------------=------------------------------------------------------(Owner and/or Contractor) ------..----`----- - - (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 i APPLICATION ACCEPTED BY---- —---------------------- ----------------------- DATE f - REVIEWED BY-------------=---= ='---------------- -- --------- ------------------------- - -------------------------------------------- DATE------------- --- •--------- ---------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations--- ---- ------------------- ----------------- ------------------------------------------------------•------------------------------------------•------------- ------------------------------------- ----------------------------------------------------------------------------------------------------•-------------------------------------•------------------------------------------ ------------------------ --------------------- ------------------------------------- FINAL INSPECTION BY Date ------�--------------------------------- 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 F ES-9-2M Revised 1.57 F.P•CO-