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dJ � � APPLICATION FOR SANITATION PERMIT Permit No. ._{_ - - (Complefe in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued --- Application is hereby made to the San Joaquin Local Healfh District for a permit to construe and install the work herein described. This application is made in compliance with County Ordinance No. 549. c � JOB ADDRESS AND LOCATION-.,. 2., _-, ` �.- Owner's Name - P / ------------ ------------------------------- Phone Address-------------------- Contractor's Name- - ----------------- ------ Phone------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: _,___ Number of bedrooms._ Number of baths - Lot size Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table �.`ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 2r�'New Construction: Yes Ifo ❑ pHA/VA: Yes Z— No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well__' -_Distance from foundation_-_ /Z/ 7---.--Material �iall--_6_ x7%'r�ie E4� No. of compartments------,�-.f _ Size --- Liquid depth---- --- Ca acit -- t - p y--?QQ.-------- Disposal Field: Distance from nearest well-----�=__..-Distance from foundation..-,le----__---.Distance to nearest lot line_.b�.------ Number of lines---_ _ -�---�--------- -Leng'fh of each line---�d'�-~--------?-- ---.Width of french-.X Type -------------- Type of filter n terial � '� D,rg.' of filter materia ---- �f'L--._.--Total length--___-_les ----------- Seepage Pit; Distance to nearist well---- -----------Distance from foundatioN---__l0 Distance to nearest lot line--- -.--.... Number of pits-_:- ------ --Lining material__,�Bl _--.size: '-'.-- -.Depth__A0 Diame r.- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------------------------ ❑ Size; Diameter------ •------------------------- ---Depth--------------------------------------- Li quid Capacity----------------------------gals. q Privy: Distance from nearest well------- -----_ -_ ----____Disfance from nearest building Distance to nearest-lot line ---------------------------------- ----- .;,,,' ' f --------------------- ------ - -------- ----------------- - --------•- ------------------ Remodeling and/or repairing (describer t�ri ..-�$ - --------------------------------------------- ------ ---------------------------------- 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. (Signed)_ --------- --------------------- - - ------- ------------- --{ r Contractor) By:------------------------------------------------ ---------------- -------------------- Tale----- (Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). .101"FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- --- ---------------------- -- ---- - ---------- - ------------------ DATE-------------- - _---- --- - REVIEWED BY ---------------- DATE -------------------------- UILDING PERMIT ISSUED-------------- ------------------------- ---•-- DATE---------------- -------------------------------------------- A terations and/or recommendations-------------- ------------- f ---------------------------------- ------- -------- �.- CPQ ----------------- ----------------------------------------------------------------------------------------------------------------------------- ------- ------------------------------------------------------------------------------------------------------- -------------------------- FINAL INSPECTION BY:. --------- ------------------- Date---------- SAN ----- -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 V59 F.P.Cc.