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APPLICATION FOR SANITATION PERMIT Permit No. .__l _a..�/ (Complete in Duplicate) Date Issued _____ cad/ Application is hereby made to the San Joaquin Local Health District for a permit'to construct and install ilia work herein described. This application is made in compliance with County Ordinance.No. 549.- JOB ADDRESS AND LOCATION---- r-- - - -- -------- ,tc --- AlOwner's Name /_7_Y#S_z_._. Phone ... ------ Address------------------------------- ----- --- C_ _ �. , Contractor's Name------------------ •�' r -- one Installation will serve: Residence 2rAparfinent House ❑ Commercial ❑ lTraileri Court'❑" Motel ❑ Other ❑ Number of living units: _ Number of bedrooms _Z__ Number of baths _t_ _ Lot size -----f- ----- ----------- Water Supply: Public system ❑ Community system 'E]- Private Depth tb Water Table,� ^Yf. - - Character of soil to a depth of 3 feet:: Sand [-] Grave I ❑ Sandy Loam P Clay Loam Ej Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made:- Yes ED--No ®"5New Construction:- Yes No ❑ FHA/VA: Yes ❑ 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 wellfrom foundation_laterial____ '_ � � r ---•------- No. of compartments____._:-_ Capacity _��-a---•- � � e----- -@Size-- -- --�-�--�-•---Liquid depth --- ----------------- p Y--• �• 0 .. Disposal Field: Distance from nearest well54-----Bistance from foundation_1.0__ "�"81stance to nearest lot line. Number of lines __ _t Length of each line_______ ��-_ "--'____._.Width of 1 _____ te Type of filter material _.� Depth of filter materral__.__ �__- _ Total length-___ Seepage Pit: Distance to rneares`t'wel-I _ --"--.;'Distance from foundation________':_..__._..Distance to nearest lot line__-_•--_________- I ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----•------------------Depth--------------------------------- Cesspool: Distance from nearest we]-----------------Distance from foundation________________ _Lining material---------------------------------_- -- ❑ t Size: Dia me#er--------- ----------------------- ---Depth----------------------------------------------------- ---•------ -----,------------- ---------------Liquid Capacity- ---------------------•- -gals. Privy: Distance from nearest well__.1------------------_______.___..._--_ 4 `- - ' t&-_-:DisF tance Ffrom_.nearest building_______---_.___________-----------------Distance'to-nearest Iot'line - J9 - ------------- Remodeling and/or repairing (describe)------------------------------------------------------------------------------------ ---------------------------- ---------------------------------------=-------------------------"---•--------- I r -----------------------------------------------------=--" -- ------•------•--•--------------•--------------------------------- ----------------------------------------------------------------------------- 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 a regulations of the San Joaquin Local Health District. {Si ned g )---- �vs. r__. f--------------------------------------------------------- -----------------------------------{ / _ -__Owner and/or Contractor) 8Y: ---------------=----------------------•---=----------------- - --------------------=--------------------------(Title)------------------------------------------------------•--------- l (Piot plan, showing size of lot, location of system in.relation to wells, buildings,-etc., can be placed on-reverse side). F�0DEP.-RTMEN USE ONLY APPLICATION�ACCE�PTEDBY DATE_. c -_:. .. ----- ---- REVIEWED BY ----- --------------------- ---------------------------------- DATE - Y BUILDING PERMIT ISSUED--------------------------------------------------------------------------------------- --------- DATE Alterations and/or recommendations---------=---------------------------------------------- ---------------------------------------------------I---- --------------------------•--•------------------------••---------------•--------•---- -------------------------------•------------------ -------------------------------- -------•--- ------------------------------------------------------------------- -----------•--••-------------•------ --------------•------------------------ ------------•-•-------••--------------------••--------------------•--•-------------- ------------------------•------------------ ------------------------------ -------------------------------------------- FINAL INSPECTION BY::"-------- =-- ---------"-- .' - - ------------- r Date-- ..er"�_/v 2-)------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California SES-9-2M Revised 1.57 FY CO. I