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r S� ,tv ° APPLICATION FOR SANITATION PERMIy T ty�j Permit No. .___ .lJ�'__ � (Complete in Duplicate) -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 Coun yTOrdinancp N:Q 549- r JOB ADDRESS CA ION -- - = -----------r� j` ` / '- a= -�'`7?"'' Owner's Name- -� "' -------•-------- Phone ` Address:_.....! ----- - __�.__ v _ ... P-------------------------------------------------------------•-------------------------------------------------•---------------- --__-- Contractor's Name---- ------ -----= -=-------------------- ---------------------- ------------------=---------------------------------------------- Phone------._--------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1------Number of bedrooms c __ Nmber of aths _Z__ Lot size / _______________________________________ Water Supply: Public system E] Community system ❑ Private Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam , Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No El", New Construction:' Yes [ No FHA/VA: Yes [?'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest wells' '_._ Qista fr foundation- 'Material.____ ------------- ci }� r r No, of compartments____________ ________ Size_ _ ? ____ __Liquidlde th.--.-----.�_____-_____Capacity--�----0--?,--___ j Disposal Field: Distance from nearest weli-t�0 _______�Disfance from foundation -D 7 __Distance to nearest lot line__S�'�-� q` ---------.. Number of lines_________ _____ �_�Len th of each line-------- '___�d � Width of trench_________ _�_�__�_ Type of filter mater ��Depth of filter matenal___ ______._Total length--------------- ______________ Seepage Pit: Distance to nearest well----------------------Distance from foundation------___":�-------Distance to nearest loi- line----------------- El Number of pits----------------------Lining material--------------------_-Size: Diameter_----------------------Depth--------------------------------- Cesspool- Distance from nearest well-----------------Distance from foundation.:`:_-_-_'f------_.Linin material-___________________-_______-__-_-- ❑ Size: Diameter------------------------- sn,. * Depth ---. - Liquid Capacity -------gals. Privy: Distance from nearest well---------------------------------------------- __Ds_SGce from nearest building_____________________________________._. ❑ Distance to nearest lot line------------------------------------------ ---------- -----!`fir Remodeling ana/or repairing Idescribel)------------------------- -- - ''. s _ _ ____________________ ____-_ -c -` --------------------------- --t-------------------------------------------------------------------------------- ------------------------------------------------------------------------=------- ------------------------------------------------------------------------ ------------------------------------ ----------- ------------•-------------.------------------------------------------------------------------------------------------------------------------------------------------------- �-�- 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 regulations of the San Joaquin Local Health District. (Si ned �} 9 )-------- '�` --- ------------------------------------------------------------ -----(Owner and/or Contractor] By:-------•------------------------------------------------------------------------------------•--------------------------------------(Title)---------------------------------------- ---- ------------------ V (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). �3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - - DATE REVIEWEDBY----------------------------� ------------------------------------------- ---------------------------------------- DATE— BUILDING PERMIT ISSUED - DATE Alterations a d/or recommendation ---,�----..�- d:::--: -_---� -�:-�----�ice-.---- ---------- --- -------------------------------------- -------------------------------------------------------------------- ---------------------------------------------------------------- --------------------------------------- --------------------------------------- --------------------------------- FINAL INSPECTION BY:------- ------------------- Date----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Souil—American Streot 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M , Revised 1�57 EP.CO.