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LL APPLICATION FOR SANITATION PERMIT Permit No. ----` `r.__ _ - (Complete in Duplicate) Date Issued ._-C f `_X�' 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. �'^ ��(w-tit/' JOS ADDRESS AND LOCATIONA' / op Owner's Name--------/ _ - ---- --------------------- - -- ---- Phone---------------------------- ----- (! y� ` Contractor's Name-___ - - - - - - - - --------------- - - --------------- Phone h Installation will serve: Residence � -`------� � ❑ Apartment House ❑ Commercial ❑ Trailer Court,n Motel ❑ Other ❑ Number of living units: c$._. Number of bedrooms -------- Number of baths -------- Lot size -'Aft �''iracy Water Supply: Public system ❑ Community system 0 Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand JJET Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No* New Construction: YesNo E] FHA/VA: Yes F1No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' , _ (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Sep is an Distance from nearestfl Distance from foundation_--_ _.Material__ ___________ tet, ------------------------ No. of compartments_ _Size- `�h __ �` 36�r y p �7 liquid depth_. _sr. Capacity- O Disposal Field: Distance from nearest well _-------._,Distance from foundation_----__--_.Distance to nearest [of line-;�-':--___•_-_ Number of lines---__---/-_.___--------- --__ _ Length of each line-_-_-�0----------------Width of trench.-r��'_________-! Type of filter materially_- - ------ - ___Qepth of filter material-__1�__________Total length__,$'Q�_____________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__----__---_____ ❑ zNumber of pits----------------------Lining material----------------------- Size: Diameter Depth ----------------------- Cesspool: Distance from" '-Size: well------_-----_---Distance from foundation__-----------------Lining material-----.--- -------------------------- El = I -Size: Diameter------------------------ ------------Depth-------------------------------------------- ------Liquid Capacity----- ----------- ---------gals. Privy: Distance from nearest well_________________________________________________Distance from nearest building g-------------------------------------- ❑ Distance to nearest lot line-___-.--__--_-________________ I ------------------------------- Remodeling and'/or repairing (descriSeJ:______________________ -----------•---------------- -------------------•--------------------------------------------------------•----- ----------------- -•----------------------------------------------------------------•------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St Ve laws, and rules and regulations of the San Joaquin Local Health District, (Signed) ��w (Owner and or Contractor) B,_ - 0 (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-- .J— --------------------------------------------------- DATE _-I_ - �. REVIEWED BY -------------------------------- --- ------------------ --------- - ------------ ------------ - DATE------------------------------------------------ �---- BUILDING PERMIT ISSUED---------------------------------------------- - -- -------------- - ` ----w-------------------- DATE--- ----------- - --- j Alterations and/or recommendations:------------------ - .-_ - - ---------------------- -------------------------------------------------- �------ --11 __i. .. ----- ---------- ---- 1 ------------- --------------------------------------•--------•--------------- --•--------- --------------_--------•----------=--------------- FINAL INSPECTION BY:--/1 Z_ _4t� .= w ---------------------- Date----�_- -- _e� - ------------------------------------------------------- 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 . Reviseci 1.-57 F.P.CO.