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i APPLICATION FOR SANITATION PERMIT Permit No. .._ _7f U_.... (Complete in Duplicate) Date Issued Application is hereby made to the San'Joaquin Local Health District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. 02--7—c)(p� _ ,,. ADDRESS AND LOCATION- '"` '---�' ____-- -- ---•-- --y1----- -- � - ------------ OB Owner's Name ------------------------ - --=---- ---=----- - -------------- Phone.----------------- ---------------------------- --------------- Q --- ' - Address " -------------------------•-------------------------------------------- -------------• ----------- --•------------------- Contractor's Name---- ---- A ---•--------------------=----------------- ---------------------------------------•-----------------------•----• Phone---------------...------------ Installation ----•-- •-- Installation will serve: Residence ®+ Apartment House ❑ Commercial ❑ TraI ler Court ❑ Motel ❑ Other ❑ 1 Number of living units: _1_____ Number of bedrooms ___ Number of baths �_�Zf__ Lot size �__-_--------------------- Water Supply: Public system ❑ Community system [] Private K Depth to Water Tablea_."ft. Character of soil to a depth'of 3 feet: Sand ❑ Gravel ❑ Sandy Loam M Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No PC New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank spi available lewithin? o Distance nearest permitted &_ ' md ---1-49 Tank. Dnof ---------------------------------------- No. - No. l of Compartments __ _Size+S °___,' l �Liquid depth____'V-----------------Capacity._. _I __.__. Disposal Field: Distance from nearest well Distance from foundation_a 7-0-_______-Distance to nearest lot line-_-_____. Number 'of lines--,3:--------- Length of each line-Za_"5'a'_S'9_`.Width of trench-_•' _'_____________________ -- --- ------Total len th__/A--a Type of filter material_��'� - ----Depth of filter material_��____�__ g Seepage Pit: Distance to nearest well---------------_------Distance from foundation----................Distance to nearest lot line__________-_____ ❑ Number of pits----------------------Lining material_----------------------Size: Diameter-----------------------Depth--------------------------------- CIP Cesspool: Distance from nearest well-----------------Distance from foundation--------------____.Lining maferial------------------------------------- El Size: Diameter------------------------------.-------Depth------------------------------------------------------Liquid Capacity--------------------- gals'\ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------_--------------------------- ❑ Distance to nearest lot-line----------------------------------------------------------------------------------------------------------------------------------------------- X Remodeling and/or repairing (describe)--------- -------------- --------------- ---------- -----------------------••-------------------•---------------------•-----------------------------•-••- -- -- --------•-----------------•---------------•-------------------------- 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 rule and regulations of the San Joaquin Local Health District. (Signed , '._._ �.f , ---------------------------- :---------------------------------(Owner and/or Contractor) IL 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 Af APPLICATIONACCEPTED BY--- -------- ----- -- --- ---------- -------- --------------------------------....------------ DATE_ - AP------------------------------ REVIEWEDBY--------------------------------------------- ----------------------------------------------------------•-- ----------------- DATE--------------------_ -------•--._....------•------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------- ---_--------------------------------------------- Alterations ---------- ------------- Alterationsand/or recommendations:----:---=-----------------------------------------------------------------------------------------•--•-------------------------------------------------------- ------------------ ---------------------------------•-•----------•--------------------------------------------------------------------------------------------------------------------------------------------- -----------------•-------------- FINAL INSPECTION BY:..,r ------------=- - --- Date_: ----------_ SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street 300 West Oak Street f 32 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO.