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FOR OFFICE U E: 1.�..�-_ 5d --------- l��l----j- '� Permit No. ------• APPLICATION FOR SANITATION PERMIT {Complete in Duplicate} - Date Issued --= ------------------ filo____ _________------------------ This Permit Expires 1 Year From Date Issued Appl3ca n is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. application is made in compliance with County Ordinance No. 544. This applic -----------•-•--------•----------------------- JOB ADDRESS A D LOCATION__�.`l____ ---- F-`-----��-------------------------••------------- Owner's Name Phone---- •------------ •----------- ---- --------------------------- Contracto_ __ -----.- Address Phone----------.. _ ------------------ r's Name--- ---------- . - - --------- Installation will serve: Residence Cr Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- I---- Number of bedrooms -a Number of baths I--- Lot size__��_`_X_.--------------------- • - Water Supply: Public system ❑ Community system ❑ Private jp-�Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe n --Hardpan [I Previous Application Made: [If yes,date----------- - --------j No New Construction: Yes No FNA/VA: Yes E] 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 --------- Distance from foundation__ ------------ Mater' al____________----___----______.._______._-_.___ r No. of compartments ------ ��--------------- Size__._ ?C -!1 ------Liquid depth____"_._- ----------- Capacity --VO�---- Disposa Field: Distance from nearest well_________Distance from foundation.-/gel...___.Distance to nearest loft line ----------------- Number of lines----------------- – —------------- Length of each line ------- 7s -------------- .-.Width of trench. .---`�f -,°-----•-----------•-- Yp p / T e of filter material____ o.Ct%f____De th of filter mafierial___%$_______________Total length ---------------------------------------- Seepage, -Pit: Distance to nearest well__1be-------------- Distance from foundation__/¢ �-r'! .__..Distance to nearest lot lin-_e-_.______---_.._ Lam" : Number of pits ----_-.._.______----Lining material. Cesspool: Diameter -_13. ___ .-.__._Depth_--__o`� _________________ 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 ----------------------------------------- rl 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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) --------------(Owner and/or Contractor] By-------------------- - Title ----------------- --- -- --- -- --------------------------- - ------------ - - --- ---- ------ - [Plot plan, showing size of to Ioc t n of syste in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY *',/------------- DATE ----_I ~ J --------------------- --- ----------- --------------------------- ---------------- BY ------------------------ _._ --- DATE------------ ---------------------------------------------- -- --------------------------------------------------- BUILDING PERMIT ISSUED -------------------------------------------------------- - - DATE Alteatio s and/or recommendations:-------------- -----------------------------------..-----•----------------...------••--------...-•---••-•------------•---•---••--------••-------------------, --------- --- ----- - ---- - - •--------- - --------------------------------•-------------------------------------------------------------•--------•-------------- ------------------- 1=1NA>; INSPECTION BY:.�----- ------------------------------•- -------•-•----- Date------ --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West oak Street 124 Sycamore Street 205 West 91h Street Stockton, California Lodi, California Manteca, California Tracy, California E13•9 REVISED 13.99 F.P.CD. 2M 6.60