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� rn ab 3 � APPLICATION FOR SANITATION PERMIT Permit No............... 9S (Complete in Duplicate) 11 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 AND LOCATION.............................. l. / ---=-- �� C T /�, k��- rF t I c S, I l C J Name_ '�.. �('. / _ Phone------------------------------------ Owner's-r /------------------- Phone... Contractor's Name__ Installation will serve: Resi ence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms ____ Number of baths __l___ Lot size ____ ________-_________ Water Supply: Public system ❑ 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 New Construction: Yes/Tj--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, Tank: Distance from nearest well l-_C'__�__ Distance from foundation __1 _( .......... Material ___ _____ No. of compartments___-_ r--------------- _'f___._.. Liquid depth____ S ______________ Capacity 1 r '” r`• Disposal Field: Distance from nearest wall__/__ / `_'_____ Distance from foundation____f _____.___-Distance to nearest lot line______ ---______. Number of lines._ _)_; _____ Length of each linergon�� zr.Width of trench ,2.X!-%--____ __ ..__ Type of filter material_ � �- _ __Depth of filter material_______l __ __.._Total length --------- sc. _____________________ 4 Seepage Pit: Distance to nearest well ---------------------- Distance from foundation .................... Distance to nearest lot line _____-____-._____ ❑ Number of pits ---------------------- Lining material ----------------------- Size: Diameter ----------------------- Depth _-__________________________ Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material -------------------------------------- 1-1 Size: Diameter -------- ------------------------------ Depth ---------------------------------------------------- Liquid Capacity ----------- --------------- gals. 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 0 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. - ---- -------- ----------- ------------------------�ar Contractor) By:------------ �. �s / � � = (Title) ------------------------------------ - --------------- ---- j -------------------- ------ (Plot plan, showing size of lot, location of system in relation` -,+6 wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------! '- ----------------------------------------------------------------------------------- DATE---- v� REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE ------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------------------•------------------------—------------------------------------. DATE----------------------------------------------------------- Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------------------- ------ -------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- -------------------------- -- ----------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------... ----------------------------------------------------------- --------------------------------- ----------------------------------``-------------------- �-�J FINAL INSPECTION BY---------------- --- - --- ------- Date Date---------------- .�-------------.._..------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street Stockton, California Lodi, California ES -9-2M , Revised 1.57 FY.CO. 132 Sycamore Street 814 North "C" Street Manteca, California Tracy, California