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.0t ±yr � D Ill APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �-� 1 bate Issued .__. Application is hereby made to the San Joaquin Local Health District for permit to/50,truct and install the work herein described. f?p Y q This application is made in compliance with County Ordinance No. 54`9.. JOBADDRESS AND LOCATION---- ----------------- ✓` "±-v-------------------------------------------------------------------------------------- --- Owner's Name -6-a r = t =``r -•-----••-----•--------------------------------------------------------------- Phone------------------------------------ Address--------------- �., ------------------ � .. " Contractor's Name-------.--•----••------•--------------• ------------------------------ -- --- Phone--------------------- ----------------------------------------------------------------- ------------ Installation will serve: Residence ,Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other p Number of living units: __/____ Number of bedrooms ___/_ Number of baths Lot size --,V- --- ___) - -------------------------- o Water Supply: Public system g�, Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 121 New Construction: Yes X No FNA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu Iic sewer is available within 200 feet.) Septic Tank: Distance from nearest well__.___Q Distance from fqundat!on-_--/�?"_.___.M t�ial___ __ _______________________________ _ No. of compartments------�--------------Size_!?_, :„}C - __._--Liquid depth-----_ Capacity_ ' ' Disposal Field: Distance from nearest well_ ------Distance from foundation__,)_o---------,Distance to nearest lot line__ < ______ Number of lines....... ------- Length of each line---e�1U-�- ~✓%____-.Width of trench---_� ________________ Type of filter material___��t7 „_____Depth of filter material___ .f--------------Total length______ 10--_______________________ Seepage Pit: Distance to nearest well______________________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--------------------- �` 1 ❑ Size: Diameter------ ------------------------------Depth------------------------------ ---------------------Liquid Capacity------------------ ---------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___--_-_____----------____________.______. ❑ Distance to nearest lot line------------------------------ ------------------------------------------------------------------------------------- ----------- Remodeling ---------Remodeling and/or repairing (describe)----------------------------------------------------------------------*----------------------------------------------------------•---•---------•--.---- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ------------------•--------------------------------------------------------•-------------------------------------------------•----------------------------------------------------------------------------------- --------------------------------------------------------------------------------•--------------------------------------------------------------------------•----------------------------------------------------------------- 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 regulaatioons"of the San Joaquin Local Health District. (Signed),.r --- ---f -----%rE,_ (Owner and/or Contract �'. By:----------- ------ -(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-------------- ---- ------------------------- - --------------------------------------------- DATE------------------ ------ - ------------------------------ -------------------- REVIEWED BY------------------------------------------ ------ ---- -------- -- - DATE---- .�' -------- . .._..-------- -� - -- - DATE--------- -- - �--- - BUILDING PERMIT ISSUED------------- ___---__-__�_____ . ____- Alterations and/or recommendations------------------ -_ --- --------------- --------__ ---------..._.----.-.---------_ ___-- _ ------------------------------ ------------------------------------------ - --- ----- - ----- --- -- -------------------•----------------------------------------------------------------------------------- FINAL INSPECTION BY-- ------ - -- -- -------------- - --- •-------- ---------- Date------ �--f ------------------------------ 5AN 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-7-2M , Revises 1.57 F.RCO.