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APPLICATION FOR SANITATION PERMIT Permit No. _ _ (Complete in Duplicate) 3/ / e{' F ��ii?3nJ ,Q�• � 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... r � _,ol-°� - ' Owner's Name--•-- �r�r� ---- ------------------ -- ---------------------- Phone ._ - .7- Address0--/-- �-------rl•-7---I --------------------------------------------•------------------------------------------------------------------------------------------•--•---- Contractor's Name ------------------------- ---------------------------------- --- ---.-. Phone----------------------------------- Installation will serve: Residence-[j� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /------ Number of bedrooms ___ _- Number of baths S-,_ Lot size __�' __ _________________________________ Water Supply: Public system ❑ Community system ❑ Private,F Depth to Water Table I t3 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam.] Clay ❑ Adobe ❑ Hardpan ❑ . Previous Application Made: Yes ❑ No•ff] New Construction: Yes RT No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if,public sewer is available within 200 feet.) Septic Tank: Distance from nearest wellA- from foundation/O_�----------Material_.&_ ------------------------- Ar No. ---------_----_------No. of compartments--12 -Size_-•_/II4-------___-Liquid depth-__ ----------------Capacity_ oor? Disposal Field: Distance from nearest weIIA_J------.Distance from founclation_l)--------------Distance to nearest lot line--4-----.-__-_ Number of lines---/-----------------------------Length of each line-/----_-----___._______-Width of trench..c.�G___----------------- __ -__: Type of fi!#er materiaYl � _ epth of filter mate rial__ -T-----------Total length---/ '--------------------------- Seepage Pit: Distance to nearest weft_--------------------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-- Size: Diarn0er---------------------------------------De th_-------- -----� ; ---Li uid Capacity p ----------------- -------------- q ------------------ -----gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______._----------______-_--_-.--_-_-.-.-. ❑ Distance to nearest lot line Remodelingand/or repairing (describe)-------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------••--------------------•-------------•------------------•----•------------ ----------------------------------------------------------------•------------------------•------------------------------------------- ----------------------------------------------------------------------- ----------------- -------------------------------------------------------------•---------------------------------------------------------- ---------------------------------------- ---------------------------------------------------•--------------------------------------------------------------- I herycerfifat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanceand rue • and regulations of the San Joaquin Lacal Health District. (Signed)_.- -- - -- ------- - �""---------------- -----------------------------------------------------------------------(Owner and/or Contractor) Cv By:-------------------_-------- -----------,....-----------------------------------------------------------------------------------(Title)--------------------------------------------------- .. (Plot plan, showing size of to locati�n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY �0 APPLICATION ACCEPTED BY_44 - - ---------------------------------------------------------- DATE_.4`1_e_-_rf---- -------------------------------- .t��, REVIEWEDBY------------------------------------------ --------------•---------------------------------------------------------- DATE----------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations:------ ----------------------------------------------------------------------------------------------•--------------- -------------------------------•--------------------•-------------------------------------------------------------------------------------------------•----------------------------------------------•------------------------ --------------------------------•------------•------------------------------------------------------------------------------------- ---------------------------------------------- ---------------•------------------------ --------------------------------------- ----------------------------•-------------------------------------------------•---------------------------------------------------------- FINAL INSPECTION BY:--. . .. --- - - ------------------------------------ Date--------- -------------- - - -• �--------- ------------ ---------------- 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 E5-9-2M Revises 1.57 FRCO. t