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APPLICATION FQR SANITATION PERMIT Permit No. (Complete in Duplicate) I Date 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 N---- - ; -------/� ----- - -----------Owner's Name---- � '' ----------------- Phone------------------------------------ Address-.-------- -----------------------------------Address_... - , r ' - y - ------- -------------- Contractor's - Contractor s Name______________________________ - _ --- `------- Phone Installation will serve: Residences Ape rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ` Number of living units: _f__.- umber of bedrooms,. -_ Number of baths ___ Lot size _______ ._r0 .-.--- -------------- Water Supply: Public system ❑ Community system'El PrivateA, Depth to Water TaUe _ .7 Character of soil to a depth of 3 feet:~Sand ❑ Gravel C] Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New 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.) , ,�de�tic T� Distance from nearest well-----------------Distance from foundation---_-----------------Material____.___.-----_-______.___________-- No. of compartments----- :�-----"- Size- -----------------------i'•-Liquid depth--------------------------Capacity-----------------= - - t Disp I;F,y _ Distance from nearest-well-_-----"'_._"--.-Distance from foundation=_ __�'---------Distance to nearest lot line_________________ �a Number of lines----------------------------------Length of each line--------- -------------------Width of trench---,------------------------------- y Type of filter material-------------------------Dep`th of�filter material"-------------`-----Total length-------..--------•_..-----------•------•- ,�q f t ,. i i' Seep ge Pit: Distance to nearest well_./ fl________Distance:,from foundation_ Distance to nearest lot line___/ ------ " -Size: Diameter---f�/ ___---_--.Depth--. --\----------------- Number of.pits----�---------------Lining material----- --, # sa` I Cesspool: Distance from nearest well_________________Distance from foundation______-------------.Lining material-.__---______-_____.____.---__.______ F1Size: Diameter------------------------ -----------Depth----------------------- ---- 11--------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building---------------------------- ❑ Distance to nearest lot line----------------------- - - ------- -------------------- •--------------------------------- ----------------------------------- s � � mss- •T ,� Remodeling and/or repairing (describe)---- _—_ = Y + __________________ __ _______-_____________________1+ _ _ _-.---.._ _._..___________--.__t _____.____._- ______________________________________ _______________ ________ - _____________________________________________________--__.._______2---..__ ___..________.____._.________________._-________________.___________________..____._.________.____._______.-_.-___________.._ ___ ______ _____ I hereby certify that I have pr pared this app ion nd that the work will be done in accordance with San Joaquin County d rule ,a d r lation of th gSan Joaquin Local Health District. ordinances, State laws, an (Signed)_ .. -_ er and/or Contractor B � :1,�_ ---------------------(Title) ------------- Y:-- - -- ------- (Plot plan, showing size of lot, location of system in relation f wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT.USE ONLY' ' 4 DATE �� --4�--------------------------- APPLICATION ACCEPTED BY------------- - ---- --------------G lREVIEWED BY------------------------------------------- ------- -------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------- --L DATE----------------------------------------------------------- Alterations and/or recommendations:- -------------- ----••----•--••-----------------•--------------•--------------------------- ----------- ------•----•-----•--•----------------- ------- --------------------------------------------------- --------- - - _ ---• ------ •--- -----------•-----------------------------------------•------------------------------ ----------f_------- - ------ ----------- w -- -- y` {`` Y � QGutszY._ t 4�. FINAL INSPECTION ,� ------ Date-- -- � ---------------------------------------------------- SAN ---• -------- --------------------•---------------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 )_57 FY-CO. �f.