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TV C APPLICATION FOR SANITATION PERMIT Permit No. .____� . (Complete in Duplicate) ' ! I'; bate issued ------:_� '�� 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. JOB ADDRESS AND LOCATI�OIg- j Owner's Name , 1/1!_`---- Phone Address--------/X /f Contractor's Name---------- -------------------------------------------------------------------------------- Phone,.--------------------------------- Installation will serve: Residence�23�partment House F] Commercial ❑ Trailer Court F] Motel ❑ Other F]Number of living units: _ "-__ Number of bedrooms j-_ Number of baths - Lot size Water Supply: Public system ❑ Community system K?'�Private ❑ Depth to Water Tableav,W4. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E❑ Clay ❑ Adobe Hardpan 0 Previous Application Made: Yes ❑ No New Construction: Yes &lo ❑ PHA/VA: Yes g�lo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) /n Septic Tan Distance from nearest welk_ Distance from foundation----- ,1------.Material------ /� �_ __ ___ No. of compartments------ Liquid dP q .th___ .__Size___, �t_ _` Q_---Li e -Ca P acit Y �--- Disposal Field: Distance from nearest well_ �__'Distance from foundation-,l"r,1�_____________Distance to nearest lot line-- ---------- P111- Number of lines______._-- ------------- Length of each line-----,To ______�r__.i_.Width of trench_.__•�Z -- Type of filter material/'�_�tDepth of filter material-._,� _______Total length--__,f_yJ��__________________ Seepage Pit: Distance to nearest well_-._ -5y,&_w,_4-'_07stance from f ndation__,,,,?Aq___.__.Dist nce to nearest lot li`_0P.!_.__-_ [�}Iy Number of pits...... __,---------Lining material_. -----Size: Diameter___ Depth_._..Lrvl _____________ Cesspool: Distance from nearest well __-____.------Distance from foundation--------------._._-.Lining material-------------------------------------- t__1 Size: Diameter------------------------- -----------Depth---------------------------------------------------_Liquid Capacity-------------- -------------gals. 1 Privy: Distance from nearest well_____________________________ --------------------------------------Distance from nearest building_____________________ ❑ Distance to nearest lot line------------------------------ Remodeling and/or repairing (describe)____________ __ __ ' - }_ ---------••-•------------------•-------•---------------------•----•--------•------------- - -------------------------------------------------------- ------------------------------------...------------------------------------------------------------------------------------------------------------------------------ I -------------- -----------------------•----------------•------------------------------------------------------------------------------•---------------------------- 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, a d rules and regu ations of the San Joaquin Local Health District. Si ned ( 9 } �-----•------------( r-Contractor) ----- - - ------ ------------- BY:---------------------_------------------- = ---------------------------------------(Title)_-::--- ------- - --- ----------------------- (Plot plan, showing size of lot, locati system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ------------------------------------------------------------------- DATE------- �� REVIEWEDBY----------------------------------------------------------------- -------------------------------------------------- DATE BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:------- - -------------------------------------------------------------------•-----•----•-•------------•---•--------------------------------------- -------------------------------------------------------------- -------------------------------------------------------------------------•-------------•-----------•--•----------•------•------------------•----------------- ---------------------------------- ----------------------------------------------•------------------------------------------------------------------------------------------------- ---------------------------------------- ----------------------------------•---------------------------- ---------------------------------I--------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------�-------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:------- 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 , Revised 1.57 F.P.CO.