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APPLICATION FOR SANITATION PERMIT Permit No. ____91/_3____--- 3 4�d (Complete in Duplicate) �/s o Date Issued Application i 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--------- ---- '� Owner's Name-------- ---- l� one ---------------------- Address-------------............................ s. '��`~� Contractor's Name_-------------------_-----f_37` x�--- --- --- -- -- ------------------------------------------- Phone,2h!Z Vf rr Installation will serve: ResidencefQ' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motelt�❑ Other ❑ Number of living units: 1-._ Number of bedrooms J___ Number of baths --- Lot size ---- Wafer _-Water Supply: Public system R'� Community system El Private El Depth to Water Table __ ft. Character of soil to a depth off3`feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AclobeX Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No [N' FHA/VA: Yes ❑ Nogg 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_________________Distance from foundation--------------------Material__--_____._.________________---__-..._______._. G ., No. of compartments_-------------------Size_....---------------------------.Liquid depth----------------- --------Capacity----------------------- Di osal Flee Distance from nearest welf---------------__Distance from foundation--------------------Distance to nearest lot line---------------_ Number of lines-----------------------------------Length of each line---------------------.--------Width of trench----------------------------------- t y Type of filter material-------------------.-----Depth of filter material------------------.----Total length--------_--_________________________-__-- Seepage Pit: Distance to nearest well _ctCr/1� _Distance m foundation___ -.___.Distance to nearest lot line,/?---------- ©-� Number of pits_____ _____________Lining material. -- -Size: Diameter__�'_'.._.-._----Depfih__ '-=_------------------- 1 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------__________.________________- ❑ Size: Diameter------------------------- ------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------_--------------------- -----------._Distance from nearest building---------- _---___________-______._. -V ❑ Distance to nearest lot fine-------------------------------------------------------------------- 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 C ordinances, Stafe laws, and rules aqd regulations of the San Joaquin Local Health District. (Signed)--------- By: ------- / {Owner and/or Contractor( I = ✓�'.. :� ,r (Title) C"-`hir By:------------------------ - ..... - (Piot plan, showing size of lot, location of system icrelation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- ----- DATE-------------------- REVIEWED BY---------- ---------------------------- - --------------- DATE -------------------------------- BUILDING'= PERMIT ISSUED------------------ -------------------------------------------------------._ D TE---- -- - --- - ------------- Alterations and/or recommendations:- ---------------------------------------------------- ----------------- ---------- ------•- ------•--•---------------------•--------- ----------------------•----------------------- ------------ ------------------ ---- - ------------- --- --------------- - - --- ----------------- - -------------- ------------------------------ ---- ------------------ - -- ---- ---- ---- - - - ------ - ------ LLL/{i _____----------- ________ _ _.___.�R__..__--- ---------------------------------------------- --- ! �- ---- FINAL INSPECTION BY: -- - 1------ ------------------------------------------ Date------- � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revisea 1.57 FRCO. �`