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APPLICATION FOR SANITATION PERMIT Permit No. __L--T_•l-_ (Complete in Duplicate) ; f � s °yQ Date Issued ______�------- u 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. dCrO —O� JOB ADDRESS AND LOC I N_ _ _______________ _' -_l:l- ..� _f - --- ------------------- Owner's Name 5 ------- ---- Phone ------------------------------ 3� Address �•� '. 7 Contractor's Name -------- - - - Phone y------- Installation will serve: Residenceu Apartment H se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ , Number of living units: --I--`--�Number of bedrooms _-_ Number of baths _1____ Lot size ------ ------•------------------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Wafter Tablet. Character of soil to a depth of 3 feet: Sand ❑ Gravel Sandy Loam W Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ s Previous Application Made: Yes ❑ NoX 'New Construction: Yes No ❑ FHA/VA: Yes ❑ No k TYPE OF INSTALLATION AND SPECIFICATIONS: (N9 septic ank or'cesspool permitted if public sewer is available wit in 6 feet.) Septi Tank istance from nearest well________________ Distance from foundation -------------------- Material --------------- -----____._____-_________ o. of compartments ---------- --- ----------- Size ----------------------------=--- Liquid depth -------------------------- Capacity -----------�-------�: Di Field: Distance from neares# well --- 1-0-____ Distance from foundation ---- .� O -_----_-Distance to nearest lot lir�e_�__--______ ^� Number of lines -------- j______ ___ Length of each line___�0_____-_f------ Width of trench.____' ,�+ ��----------_- Q��`/'%r•A`� Type of filter material_- Depth of filter material___-._ ----- __._Total length____S`�---------------------------- NIS. Seepage Pit: Distance to nearest well______________________Distance from foundation____ -•---__________.Distance to nearest lot line______.---_____ ❑ Number of pits ---------------------- Lining material ----------------------- Size: Diameter ------------- ----------- Depth _____-_--------___________------- Cesspool: Distance from near st well-- - �D tante from foundation _ ,5 Q------- L9 aria ------------ ---------------------- Size: -_ _LLII`` yr --- _ Li uid�Ca acit _._::-- Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building ---------- -------------------------------- ❑ Distance to nearest fot line_____________________ Remodeling and 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. r (Signed)--_-- ----- _ {-------------------------------------------------------------------------------------------- (Owner and/or Contractor) By: ------------------------------------------------------- ----------------------------------------------------------------------------(Title)------------------------------------------ -------------------- (Plot plan, showing 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---- ------------------------- -- -------DATE ------------------- REVIEWED BY - --------------------------- DATE------/= BUILDING PERMIT ISSUED _---•-- ----- - -------------------------------- .... DATE------------------------- Alterations and/or recommendations: ------------------- --------------------•------------------- i —=-•-----------------------------------------------------------------------------------------------------------------•----------------------- ------------------ ________________________._�___ _ _________________________________________ FINAL INSPECTION BY:. --- Date ------------------- l ------ 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 -9-21x1 . - itevisea 1-57 F.P.CO.