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APPLICATION FOR SANITATION Permit No CYN/ ON PERMIT(Complete in Duplicate) 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. J013 ADDRESS AND TION f� -- --------------------------------------- -------------------------------------------- Owner's Name------------- -------------------- Phone ' , Address_..._.------- --.��--- - -- ---- - - --- -- ------------.--• ----------------------- - -•-•--------------------------------------- Contractor's Name_ -----Vol Phone :. - � Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel,E] Other 4 Number of;bedrooms�__ Number of baths _ -."- Lot size __ Number of living units: - _ `` ' Water Supply: Public system ❑ Commuriity system ❑ Private Depth to Water Table 7-19 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravei ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ J 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.) f /� I e f D --`-----�C�J--`----� -- Septic Ta k: Distance.from nearest well/�.Q_____Distancce ro�m/'foundtion___:,! a e�Jal__C._f_____ No. of compartments------.-_--G�r- ----------Size__4�----X34--------Liquid depth__/-:�---- --Ca Capacity f P y---_c�- i Disposal) Field- Distance from nearest well-� .___.-Distance from foundation f_ Q__r_____Distance to nearest lot Ike------------ Number of lines______ "__ ---Length of each line__7d___- -2-w.---Width of trench___ Type of filter materia4,�� _+__ ____ _ --Depth of filter material_ __AV--------Total length------------------ -- -=----------�- Seepage P Distance to nearest wel4__/----------Distance rom undation____ _ Distance to nearest lot line________________ �� Number of its----- ------Lining material_,-----Size: Diameter--- ------------Depth__rs-------------- ----- Cesspool: Distance from nearest well_---------------Distance from foundation-------------------.Lining material__.________-----____-_____._____-_._ ❑ Size: Diameter------------------------------------- Depth----------------------------------------------------Liquid Capacity---------------------- ----gals. Q Privy: Distance from nearest well------------------------------------------------- from nearest building------------------------------------------ ElDistance to nearest lot line----s----------------------- ------------- --------------------------------------------------------- ------------ Remodeling and/or repairing (describe): ----•------------•--------- -------------------------------------------------------- -------------------------------------------------- --------- •--------------------------------------------------------------------------•----------------------------------------------------------------- ------------- I her ertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, t e laws, anrr and regulations of th San Joaquin Local Health District. r �j (Owner and/or Contractor) (Signed)------ !!-' ------- -------------------------------------- By:--------------_----------------------------------- - -- ---------- -------------` Title _ -a_ -------------------------------------------- (Plot plan, showing size of lot, location of system in relation to ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY, ----- DATE--------- __-�/ - APPLICATIONACCEPTED BY_ - •-------------=--- - -- - - --- -------------------------------------- - - �„� -------------- REVIEWED BY--------------------------------------------- -------------------- DATE_ ------------------------------------- -- - BUILDINGPERMIT ISSUED---------------------------------a----------------- ---------------------------------------------- DATE---------------------------------------- --------------- Alterations and/or recommendations.------ --- ----------------------------------- ------------------------------------------------------------.-------------------------------------------------- ------------------------------------------------------------------------------------------ -------•-----------------------------•----------------•------------------------------------------------------------------------------------------ - ---------------------------------------------------- ---------------------------------------- ---------------------- 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 . Reviseci 1-57 r-P.CO.