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mit No !_._�}_..f�_ APPLICATION FOR SANITATION PERMIT Per . ._ (Complete in Duplicate) a . 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.1549. a ,} JOB ADDRESS AN LOCATION-------- _.:,� --- 1------------------------------------------------------------------------- Owner's Name------- _ r R '---------------------------------------------------- ----------=--------- --------------- - Phone-- -1------- ----�L�-- -----------------•----------•-•--=-------------------------------------•-------------•---------- Contractor's Name-------------------------- -------------- --------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ElCommercial ❑ Trailer Court [-] Motel ❑ Other, ❑ Number of living units: -1------ Number of bedrooms _-______ Number of baths - L'ot size ------j - ---- Water Supply: Public system"N4 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's`. New Construction: Yes' ' 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 well_ �' pistanc __.:__.. e from foundation__ .-`------ Material_ -at _Cr r _ 1 x _LiquI iclepth---------- - ---------Capacity-•--- = O` ,�• �.No. of compartments -- ---- - - DisposalField: Distance from.nearest �X�t-_Distance from foundation__:__1L________.Distance to nearest lot line____.__-----_ • :. © Number of lines____ at-_._.__'__- --- Nu of each line-'2�_- - Width of trench'-,_, /-f- ____________ Type of filter material__=__ _V Depth of filter material----V ._!�_____.-_-Total length______; YP - Seepage Pit: Distance to'nearest�well______________________Distance from foundation_______,______..___.Distance to nearest lot line_______.---____._ i Number of pits- --------------------Lining material---------------------- Size: Diameter -----.Depth------------------------------- Cesspool: Distance from nearest well--_____._-___._-Distance from foundation____________________Lining materia!_______________.____________________ ------- als. ❑ Size: Diameter_ ------ Depth_ Liquid Capacity g Privy: Distance from nearest well___y__--_.___----_:-_-.------------------------Distance from nearest building_-----____.___________------------------- ❑ Distance to nearest'lot line --------------------°---------------- .F.--,-,------------•-------------------------------------------------------------------------------- • . . 6 Remodeling.�and/or repainng (describe]--------- --- =---- ''►"1'�'-----��'�Z'l.'`-`---- s�=------- ---••----�--- ! r � ,�-. ---- ' ------------------------------------- --------------- - -------------------- - ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ------- ---------------- -------------------------------------------- (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 APPLICATION ACCEPTED BY--------w u ------- = --------------------------------- ------ DATE------ - = / -- ------------------------------ DATE----------------------------- REVIEWED BY------------- --------------- ----------- --- --------------•- ---------- -- -------- ------------------------ ---- BUILDING ---------------------- ----- BUILDING PERMIT 1SSUED------------------------------------------------- -------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations---------------------------------------- ---------------------------------------------------------• - ------------•---------------------------------- 1 -------------•---------------•--•---------------------------------------•_------------- ------------------------------------- ---•--------- ------•---------- --------------------------------------------------- - - � 1 Date --------------------------------•---- --- FINAL INSPECTION BY:.___�C.�L��.�--�- - ------- - -- - tNCAL ,SAN JOAQHEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1.57 F.P.CO. ,