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i I APPLICATION FOR SANITATION PERMIT Permit No. {Complete in Duplicate} Data Issued i 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. 4 a JOB ADDRESS AND LOCATIONz`'' / '°J ---- ........... Owner's Name--------- .�r'��1 ------------ ---- - ---------------------------------- -------- Phone------------------------------------- Address --- ------/.........04"V---- -- ---- -------------------------------- Contractor's Name--- xrc----------------------------------------------------------------------- ---------------------------- ---------------- Phone----------------------------------- - - Installation will serve: Residence 43' Apartment House Commercial Trailer Court d p ❑ ❑ ❑ Motel ❑ Other ❑ Number of living units: /_____ Number of bedrooms J__ Number of baths l_____ Lot size ---bz--- ________________________________ Water Supply: Public system ❑ Community system ❑ Private, Depth to Water Table _k-0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No lZ New Construction: Yes j0 No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is availabl within 200 feet.) Septic Tank: Distance from nearest w II___ d_____Distancejr Qun�tion___IU________-Material______--_ --------------------------- i] No. of compartments--------------------------Size_4�__;*' ------__-__. _QLiquid depth-----------------------Capacity_//PV- ---_-_----- Disposal Field: Distance from nearest weilr_4---------Distance from foundation__/D-----------Distance to nearest lot line__tr......... Number of lines------ —___________ _ _ Length of each line-----1�-9_-________________.Width of trench-.2_��_____.______________ Type of filter materia Depth of filter material -________Total length-1.2,47 - Seepage Pit: Distance to nearest weil_l07P----------Distance from foundation___—e.______..Distance to nearest lot line___-------.--__. ~ e Number of pits.-A---_________Lining materiaf4�_-Size: Diameter_.__�_3__ -------Dpth_ ,,?-r_----__.______________ 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__________.__---------____________.______- ❑ Distance to nearest lot line-- --------------------------------------------- ---------------------- Remodelingand/or repairing (describe)-------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------`-------------------------------------------------------------------------------------------------------- rh --------------------------------------------------------------------=----------------------`---------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------•--•-------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby ertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S to`aws, an r es and gula ions of�the Sawn Joaquin Local Health District. (Signed)_ . •----------- ✓" - {Owner and/or Contractor) By: - --•--------- ---------------------------------------------------------------------------------------(Title)--------------------------------------------------------------- (Plot plan, owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ _ ___ REVIEWEDBY------------------------------------------------------------------------------ ----------------------------------------------- DATE----------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations--------------- ---------------------------------------------------------------------------------- ---------------------------•-- ----------------------------------------------------•------•--------- -------------------------------------------------------------------------------------------•----------------•-------------------------------•---------- -------------------------------------------------------•--------------------------------------I----------------------------------------------------------------------------------------------- ------------------•- ------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 4/- -------------------- � � � -- � -- �2FINAL INSPECTION ~�r -------------- 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 E5-9-2M . Revisea 1-57 F.P.CO. r