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r APPLICATION FOR -ANITATION PERMIT Permit No. ___ .............. (Complete in Duplicate) l Date Issued ---___�/�__ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. `his application is made in compliance with County Ordinance No. 549. ,� JOB ADDRESS AND LOCATION �f 7 .---------- - ----- f/��{5 / Owner's Name � � `' � Phone Address------- ---- - k ----- ----- --- - - Contractor's Name. ---- X ------ - 7 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel [❑ Other Number of living units: __I____ Number of bedrooms __ ,__ Number of baths --.1-- Lot size ___ ---lcZa'----------------------- Water Supply: Public system ❑ Community system ❑ Private 4 Depth to Water Table 101- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,4 Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes'❑ No FHA/VA: Yes ❑ No X N. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) IT— Septic Tank: -Distance from nearest well-----------------Distance from foundation--------------------Mat erial-------.----------------------------------------- No. of compartments-------- •-k----------Size--------------------------------Liquid depth...-__--�---------------Capacity----------------------- Disposa ield: Distance from nearest well- _._._____----Distance from foundation."- __�Distance to nearest.lot line_________________ Number of lines--------------------------------*-Length of each line------------------------------Width of trench.---- --------------------------- ti� �ype,of filter material___________ _________'Depth of filter material----.------------------Total length____--__--------_______.____________-____- ,d I ,,�,Q Seepage Pit: Oisiar�ce to nearest welL___� d!/ '�DiStanCE from fo dation__f� Distance to nearest lot line__ _ Nu e'r of pits.------/------------Lining material--- ___ -- .Size: Diameter-- .3 _ ------.Depth-------c ,� --------- 11 Cesspool: Distance from nearest well�__Y_________.__Distance from foundation_._________________Lining material__ ❑ Size: Diameter----------------------------- Depth----------------------------------------------------Liquid Capacity----------------------------gals. f Privy: Distance from nearest well---------------------------------___..-----------Distance from nearest building__________.-_.-_---------_--____________-- ❑ Distance to nearest lot line--_____---------------------------------------------------------------- Remodeling and/or repairing (describe):----- Il,--a1-�'--h-------------I-------------I------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- , ------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - 'I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County brdinances, State laws, and rules and regulations of the San Joaquin Local Health District. ate_ - 'r��----------------------------------------------(Owner and/or Contractor) (Signed) o �a ---------------------- --------------------------------------(Title)----qtr---- _ ---- - - ---- ------------------------ (Plot plan, showing'—Mie of lot, location of system in relation to wells, buildings, etc., can be placed on reverseide}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- - ----------------`~ .----- --- ---------------------------------------- DATE---- ----------------------------- REVIEWED -- - -- - REVIEWED BY------------------------------------------------------------------------------------- -------------------------------------- DATE------ ---------------------------------- ------------------ BUILDINGPERMIT ISSUED------------- ---------------------------------------------------------------------------------------- DATE -------- ----------------------------------- Alterations and/or recommendations--------------- ---------------------------4---------------------------------------------- -------------------------i. 11----------- ------------------•----------------- --- -- ---- - ---------------------------•--------- -------------------------- , 11 De ------------------------------------------------------ FINAL INSPECTION BY:------ _ -. ---A/1------ ----- --- - 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 , Revisea 1-57 F.P.CO.