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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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 Count Ordinance No. 549. oY3 N acP q� -17 JOB ADDRESS AND OCATION_._.__ ._ . - _ 7576) Owner's Nam - .... .... ..'� -.-------- --'--------------------4----------------------------- Phone.'Lf� �_ . .,. _ - . Address9 ----------- ---------------------------------------•------------- --------------------------......._..--••---••----------------------- t Contractor's Name----------------- �------- Phone- - i -------- o,---------------------- ----- Installation will serve: Residence [apartment House ❑ -Commercial ❑ Trailer Court ❑ ?Mot'ell ❑ Other ❑ Number of living units: -------- Number of bedroom`Number of baths - Lot size 5J- _e+ --_ _ ± --------------- ---------- Water ___ ____Water Supply: Public system ❑ Community system ❑ "Private'[Y'Depth to Water Table ___ ft. Character of soil to a E] E] _ depth of 3 feet: Sand Gravel Sandy Loam E❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 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 T nk: Distance from nearest well_ �_____ Distance f om-foundation__/_Q________-Mat rial-_ T_ !�"-'G/°"�-. No, of compartments__._-,---- __ Sizeti' ____ -9______.___Liquid depth____ _______._---Capacity___r�+� Disposal Field: Distance from nearest !I__` ®. __.Di stance from foundation-- '.Distance to nearest lot lin�A"` _ _' ®/ Number of lines_______.___.__-.-___ _- Length of each line -7----------`— Width of trench ____�N_A Te of filter material__'_____ yp —_ .Depth�offilter material----- length._--f��' ---------------•--------- Seepage Pit: Distance to neareself� �_ ___.___Distance f undation__ �` Distae to nearest I t line -� __'�_ � Number of pits_____ --------------Lining material__' ----------- Cesspool: ► `==:Size:Ziameter-s3s--._________.Depth_'__ _•_______________ Cesspool: Distance�friom*nearest`well -______Distance from foundation_________________Lining material-------------------------------------- - ..�� ❑ Siz r€Diameter------ ---------------------------Depth----------------------------- --- -----------------Liquid Capacity----------------------------gals. Privy: Distia-rice from nearest wel!-------------------------------------------------Distance from nearest building ❑ DistAce to-nearest lot line----------------------------------------- ---- -------------g Remodeling and' repai ring (describe} 5; _ py 1 -------------------------------------------- _--------------=------------------=----------- ---------------------------------------- ------------------- - - ---- ----;----------•----. -----------------------------------------•- -------------•---------•-------•-------•--------------------------------------------------- I hereby certify that.l have prepared thrs appfrcatroR and that the,work`will be done in accordance with San Joaquin County r\ ordinances, State laws, and rules and regulations o€ the*San"Jo qurn Local 'HealthrDiisstrict. \� (Signed)_ - =: F ' " --- -------------------- ,-------------------------------------(Owner and/or Contractor) �Y= ------------------------------------------------------------------------- -------- ------(Title)-------------------- (Plot plan, showing size of.lot, location of system in relation to wells, buildings, e� t Ncan be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- -` --------------------------- �,.+ DATE------ REVIEWEDBY-------- --•---'--•-------------------------------------------•---------------.-------------------------------------------- DATE------------------------------------ ----------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:---------------------------------------------------------------------------------------------------•-----------------------•---------------------------••--•--- ------------------ .'L- ---= �� y r .- ------------------------------------------------- -- -- - - --- ------------ ,d 'u /FINAL INSPECTION BY---------------- -------------------------------- ---=-- _ Date--- ----- � '�/r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 4132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California '� Manteca, California Tracy, California ES-9-2M , Revised 1.57 F.P.CO.