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'yPermit No. .__/ :� L.� ___ APPLICATION FOR SANITATION PERMIT ' [Complete in Duplicate) : . _ Date Issued Application is here made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his application is Aade in compliance with County Ordinance No. 549 JOBADDRESS AND --------------------- /--- -- ---- ----- - - - -- -- -------------------------------------------- Owner's Name-- �:____ _ _ __Phone ----�3 ------ Address------- -- ---•-- -----=- - -- -------------------- -------------------------------------------------------------------------------------------- ---"-----•------- !: I Contractor's Name' -------- ------�--------. ---------- -------------------------------------------- Phone r Installation will serve: Residence Apartment ouse ❑ Commercial ❑ Trailer Court ❑ Motel [❑ /Other ❑ V 45 Number of;Luing units: _ ------ Number of bedrooms _ ___ Number of baths __/__ Lot size ---------------------------- 4M Water Supply: Public system Community system ElPrivate ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado b� Hardpan ❑ Previous Application l ade: Yes [DNa New Construction: Ye No E] FHA/VA: Yes El NOV ( TYPE OF INSTALL AND SPECIFICATIONS: t (No septic tank`or'cesspool permitted if public sewer is available within 204 feet.) ,tic T nk: Distance from nearest well-_--____________:Distance from foundation___________________Material_______________..-____________________-________. No. of compartments--------------------------Size--------------------------------Liquid depth----------------------- --Capacity._-------------------- r` Disposal field: Distance from nearest well._______________Distance from foundation__-________-____--Distance to nearest lot line----------------- ElNJmber of lines-----------------------------------Length of each line-----------------------------Width of trench---- 0 Type of filter material----------- -------Depth of filter material--------------- -- --Total length----------------------------------.----"- W i 1 g ----- Size: Diameter_ '- 3-- -------De th--- t lin fir`------- j Humber of pits--- ----------- -----Linin material p Seepage Pit: Di"stance to Weare t well rzz�"_------Distance from oundatio Distance to nearest o I '. Cesspool: .. Distance from nearest well-----_-----------Distance from foundation-------------- _._.Lining mater�aL__�*__�___ ____________ ❑ # l Oe: Diameter----------------------------- -------Depth------------------------------------------- --------Liquid Capacity--- ------------------------gak. i � i - ! _ ----------------------- --- f /^ ivy: Distance from nearest well _____________________ ________-____.____Distance from nearest building.l ❑ Distance to nearest lot line------ ---------------------------------------- t � Remodeling and/or ripairing (describe):-------- -- -- -- ------ y ---------------------- � ,---------------------------,-------------- -�-------------�--- ---- ------------ ------- f ... ----------------------------- ------------- 1 --. - ------- ---------------------------------------------------- --- --------------------------------------•---------"---- w I hereby certify th-at I"have prepared this application and-thaf+he work will•l e one in accordance with San Joaquin County ordinances, S law d rules and r lations of the San Joaquin Local Health District. (Signed) ' (Own /or Contractor) ----- ----- ----------------- By:-----------;-------- - ------------------- -------------------(Title =' [Plot plan, showin size lot, location of system in relation•to wells, buildings, etc., can be p ed on reuse O&e). o � t s FORLDE WRTMENT USE ONLY APPLICATION'ACCEPTED BY-= ------------------ - ------- ------------------------- DATE `` ' • - \ ---------------------------------- DATE-------------- - �1-------------------------------- REVIEWED By- 0, PERNSIT dSSUED - ------- --------------------------------- DATE — - ----= f--------- Alteratioand/off; ions:-------------- ------ - ---------------- -------- -----=- ---------------------- •_----- -- --------------------------------------------- ns i } r _.._� ---------------------- --- _ _� _ - -------r-=------------------- - ----------- ---------------------------------------------`°--------------------- �.+ ------------------------------------------------------- :----- -- - FINAL INSPECTION BY:------ Date, Y' ; -------------------- ------ --- SAN JOAQUIN LOCAL HEALTH DISTRICT ` 130►South Amlliricen Street a Soo West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, elifornia Lodi, California Manteca, California\ Tracy, Califoinis ES-9-2M t Revisea 1.57 F,P.CO. l