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f "1 APPLICATION FOR SANITATION PERMIT Permit No. _____ __. _.7.."----- (Complete in Duplicate) Date Issued ___.___/1--�--�--- Ap ication 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. n�z /!/f YY ------------------------- JOB ADDRESS AND LOCATIOhon ------------ Owner's Name----'---- ---------------- ---------------------------- - - ---------,------------ Phone--_e - ------------ Address- ------- ��••----- -- ------------ # Phone-----------•---------------------- Contractor`s Name .. s " * ------------------------. -------- -- - -- - --------------- Installation will serve: Residence [Apartment House,;-❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: _ "__. Number of bedrooms �`" Number'of baths___.f__ Lot size_�� ---��;-------------------------- -7- - -- 1 F - i Water Supply: Public system��Commuriity system 0'' Private ❑ "Depth to;Water Table _ 'ft`. 'N ` 1 Character of soil to a depth of 3 feefc"°Sand❑ Gravel ❑ Sandy Loam Els Clay Loam ❑ Clay ❑ Adobe .-- lardpan ❑ z Previous Application Made: Yes ❑ No New Construction: Yes [�TVo ❑ FHA/VA: Yes �^ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:' (No septic tank or'cesspool permitfed if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_- ,rr...=Distanceffrom foundation_----"""--Material___-_�____.__ No. of compartments_-----9 ---------------S•sze- 6'--f -- Liquid depth__. Capacity---- - '� Number of lines__T_____________________________ Len th of each line____ ""- Distance to nearest lot line.--_____________ Dis osaI F' Id: Distance from neared well__________________Distgance from foundation�N "� -------------•Width .of +ranch----------�---" - �i Type of filter matenaL_ _;�Depth of filter material____�f----_.------Total length_____" � ------ SeepPit: Distance to riearest wet! _:_ _ Distance from f10_u�nation______..______.___.Di t n to nearest lot #ine_-____________. ageAs Number of pits.--.:_-/------------Lining material ��y�_..Size: Diameter___ .____.___..Depth--, - _ Cesspool: Distance fromnearestwell-----------------Distance from foundation--__.----____._--_.Lining material--------------------------------------- Size: _.-__-_-____--____._----______ _.._. [�" -- Is. "V ❑ Size: Diameter- ------------ ------------ ----Depth----------------------------- --------------- ---Liqui.d Capacity-------- -------- g t ..---____._---Distance from nearest buildin Privy: Distance fromtnearest well -------------------------------- g----- ------------------ ----------- i -=---------- ------ -- - --------------- ❑ Distance to nearest lot.line----------------------------- ----------= ------------ Remodeling and/or repairing (describe):_: s ----------- ----------- ----------------- ------------------------------•----------------------------------------------------------------------"------------------------------------------- I hereby certify that I have prepared this application and thaf the work will be done in accordance with San Joaquin County ordinances, State laws, an rules and regulations of the San Joaquin Local Health District. / = ------------------ r Contractor) B - ----------------- -- - ---------------------------------------------(Title)- ; - - ----- ---------------------- [Plot plan, showing size of lof, to on of system in relation to wells, buildings, etc., can be place on revers side). FOR D PARTMENT USE ONLY A � DATE------------------ APPLICATION ACCEPTED BY----------- ---+- �, �- - - --------------------- i DATE------- ---------------- REVIEWED 'BY------------------------------ - ----- --- ------------------------------------------------ BUILDING PERMIT ISSUED------------- ----------- ` - - DATE---------�------------------------------------------ Alterations and/or recommen tions:_.----- ----M------------- `--------------I--------------- ------- .._..----------••-------------------•--------------------•------- - 1 .•� ��T'� #. 1------ c-7-------- ----- �=-------------•------------------- r ... - ---- -- -- -- - --------- ------------ - .. --� --------------- FINAL INSPECTION BY:.- Date '��'�'" 5 SAN JOAQUIN LOCAL HEALTH DISTRICT ' 130 South American Street 300 West Oak Street c 132 Sycamore'Street 'y 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 FY.CO. 1- l