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^� APPLICATION FOR SANITATION PERMIT Permit No. _ 2_4_2k (Complete in Duplicate) 3 � Date Issued �� made to the San Joaquin Local Health District for a permit to construct and install the work herein desc Application is hereby rvbed. This application is made in compliance with County Ordinance No, 549. JOB ADDRESS AND LO - ---- L - ----.. - Owner's Name Phone- Address Q" �`f " -- -------- Contractor's Name__ ------------•-------------- -------------------------------------------------------------------------------------------- Phone------ ----------------------- Installation will serve: Residence 4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _l_____ Number of bedrooms J____ Number of baths _/_____ Lot size Water Supply: Public system ❑ Community system ❑ Private TJ Depth to Water Table __ ____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑_Sandy:Loam ❑,,,4Clay LlamJRJ Clay ❑ Adobe E] Hardpan ❑ Previous Application Made: Yes ❑ No 2 New Construction: Yes-fR No ❑ FHA/VA: Yes ❑ No E]TYPE•OF-INSTALLATION-AND.SPECIFICATIONS '(No s0ptic tank`ar cesspool pe mitted,if,publ c sewer is available within 240 feet.) � `j Septic Tank: Distance from nearest well--- _'*-.Distance from foundation_____)_e!-_____-Material---��,`� --------------------- --- _ ® No. of compartments-----°�------------ -_-----_:---Liquid depth-----y- Capacity_. n_- -- r1b Disposal Field: Distance from nearest well--- from foundation___- -_..__-.Distance to nearest lot line____'_______ ( Number of lines________-__I-------------___ _____Len th f each line_______6_Q__'_________._.Width of trench___q --_____________ Type of filter materiaL__f-�w__� _ _ ,filter.material '1�� _____.__Totallength--- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- . r ❑ Number of pits_ ------------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------------------_- ' i Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining material------------------------------------- El ___.._____________-__-_.______ ____❑ Size: Diameter--------------- ---------------•-•----Depth----------------------------- ----------------------Liquid Capacity-- -------------------------gals. Privy: Distance from nearest well-----------------------------------.-------------Distance from nearest building___-_____________________________._______ ❑ Distance to nearest lot line------ -------------------------------------------------------------------------------------------------------------------------------------- =' Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------ -------• 2 ------------------------------------------------------------------•---------------------- ----------------------------------------------------------------•------------------------------------------------------------------ 1 -------------- -----------------------------------•-----------------------------------------------------------•--•--------------------------•---------------------------------------------------------------------------- ----------------•--------------•--------------------------------------------------------------------------------------------------------------------- -- 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. I M [Signed) ------- --- ----- -----------------------------------------------------------------------------------(Owner and/or Contractor) By:-------------------- -----------------••-----------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Piot 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- --------------------------------------------------------------- DATE___,"l-Jll -------------REVIEWED BY BY---------------------------------------------------------------------------------------------------------------------------- DATE----------------------- BUILDING PERMIT ISSUED------------------------------------------- ---------------------------------------------------------- DATE Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- _ w - +meg ------------------------------- ------- ------------------------ ---------------------- --------------------------------------------------------- ---------------------------------------------------------------- ----------------------- FINALINSPECTION 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 ES-9-2M , Revised 1.57 F.P,CO.