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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) C .Y 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. 549. JOB ADDRESS ANLOCATION ��r --------- ---------- --------------------- -- --------- - - ---- -- - - ------------- Owner's Name- - ------------------------------------ Phone. Address -- y� __e_----------------•---- -�---•-- -.�-- --- — - Contractor's Name--- ------ la-----X.41------ ------------ ------c ;}-'J ------- Phone----------------------------------- Installation will serve: Residence 9K Apartment House ❑ Commercial ❑ Trailer Court ❑ /Mote ❑ Other ❑ Number of living units. __/___ Number of bedrooms _/___ Number of baths ___f__ Lot size _____/_- � Water Supply: Public system ❑ Community system ❑ Private K Depth to Water Table4--ft. Character of soil to a depth of 3 feet: Sand Ej 'Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [1d Hardpan ❑ Previous Application Made: Yes ❑ No 0 New Constr ion: Yes No FXL` FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: o epticl, nk or'cesspool permitted if public s,pwer is available'within 200 feet.) t �] l f . an Distance from nearest well----1_� __Distance fr yy�dat r�r---, --------Material__F7� ----- ----------- j -- - No. of compartments--------- ------------_Size---- �- � depth - � � �=----------Capacity-- - f is Field: Distance from nearest w -�Distance from foundationC_� �Distance to nearest lot line___ -------- is Number of lines---------- _/.'__ 9 _-r _---Length of each fine_____. � �- of french -- Type of filter materia---- ___ epth of filter material___-- -,(,cy _ _ ______ __Total length__ ___ --------------------- Cl Seepage Pit: Distance to nearest w I------------------ __Distance from foundation___________________Distance to nearest lot line----------------- EJ Number of pits------------ ------ ening material-----------------------Size: Diameter-------------- --------Depth------------------------------ - I Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material----------- _______._______________-_. r , ❑ Size: Diameter-------------------------------------Depth----------------------------------- ----------------Liquid Capacity----------------------------gals. "U Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line---------------------------------------------- ----------------------------------------------- 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, andd rules and regulations of the San Joaquin Local Health District. (Signed)_._j' __11-44171-1-V6 1" 417J -----------------------------------------------------------------------------------------------------------------Owner and/or Contractor) By:-------------------------------------------------------------------------------------- ---------------------------------------------(Title)---------------------------------------------------------------- (Piot 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. l` ------------------------ -- --------- REVIEWED BY----------------------------------------- DATE -------- BUILDING PERMIT ISSUED------------------ -- ---- - -- ------------•---------— ------ DATE -- -------------- A aerations and/or recommendations: -------- ------------ - ----------------------------------•--------------•------------------------------------- -------------- ----------•------------------------------------------------------------------------------------------------------•--------------•-------••-----------------••------------------- - --------- - ------------------ ------------------------------ ------------------------•------------------------------ ------------------------------------------------- --- -- --- - - --- - FINAL INSPECTION BY: - -- - ------ Date------------------------------�a SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street S+ockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised 1.57 FY.CO.