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�- APPLICATION FOR SANITATION PERMIT Permit No. .___/.d_ =7_._ (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 County, No. 549. ,� .. _ . •� • -: rte. JOB ADDRESS AN OCA N----- -- ------ - #¢ - Owner's Name " --- Phone ---_--------------------•-- AddressO -- �y kContractor's Name--------•------- •--------------- ----------------------------------------------------------------------------- •----•---------•--- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motelp T Other o Number of livingunits: _---- Number of bedrooms �j � � �_-_ Number of baths _�___ Lot size _.,��l,_._�_____f_____��................. Water Supply: Public system ❑ Community system riva`te ❑ 'Depth to Wafer Table _ff__,�ft: Character of soil to a depth of 3 feet:' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe lardpan ❑ Previous Application Made: Yes ❑ No`A�New Construction: Yes tr"'N_o ❑ . FHA/VA: Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or°cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest welL_')24*1A_--Distance f om foudation-_/�-----_ Ma-teria-l j-. No. of compartment,_--_-19- ----------.--Size__sJ�----x� Q--Liquid de th--.-- -��---- C,a.__a_cit _ Y----- - Disposal Field: Distance from nearest well�istance from foundation-- Disposal to nearest lot Number of lines-------- -------- -- Length of each line---_-�"2_- f_._-------.Width of trench-----�:yrJ-------------- 01 T e of filter material_ -De th of filter material_-- �� YP P _Total length, f Seepage Pit: Distance to nearest wel __�� istance f "Ountion---_ ._..Dist n to nearest lot��I'I�ne --------- Type __.__ t Number of pits------ materialze: Diameter-_ ----Depth r!_---_____________ Cesspool: Distance from nearest well------------ ----Distance from foundation--------------------Lining material---------------._----_-___--.___.--. ❑ Size: Diameter_--------------------------------------Depth-----------=-------------- ------Liquid Capacity----------------------------gals. Privy: Distance from nearest weft-.-.-----.-_.------.--_F.-_----_-----=----_Distance from nearest building-------------------------------------- - ❑ Distance to nearest lot line------------------------- --- ------------------------ -------------------- ----------- " _ y� 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 rule nd regulation of the San Joaquin Local Health District. 1 Si ned �P�-- 1 ( 9 }-•• ---•- -------------- -------- - --'-�----- - - -- -- ---- -�f---�------ - ----------- --- - - Contractor) By:-------•----- ... ------- -----------------------(Title} ' f `---------- (Plot plan, showing size of I ocation of system in.relation to wells, buildings, etc., can be placed on rever side). FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY----------------------- --- - ---- -----------------•--------------------------------------- DATE---,,>..- REVIEWED BY -- ----- -------------- ---------------•- DATE_ \ ------------- ------------- BUILDING PERMIT ISSUED____________------------------ ------ --- DATE-- __-- -----__- -- , _ Alterations and/or recommendations:--------=--------- ------------- ---`--- ----------------------------------------------- ------ -- -------------------------------- ----------I--- --------------------------------------- Ar - - ----------------------- FINAL INSPECTION BY:---- . _ y- Date---- --_-:.-- --- ---------- -- ------- - �""2� =•-� SAN JOAQUI CAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street { t Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Raviseu 1-57 FY CO.