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-� APPLICATION FOR SANITATION PERMIT Permit No. 5J -��" \ (Complete in Duplicate) / I `► Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct •--ZCa ll he w This application.is,made in Compliance with County Ordinance No. 549. and install the work herein described. JOB ADDRESS AND LOC"'*TION__ Owners Name _f s •- -------- -- ------ -------- Address Phone. -•----•----- Contractor's .Name___ _ - - ,_ - --------- ------------- Phone.---•-.•- lnstallafion will serve: Residence �p ` arfinent House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ "- °�` Number of bedrooms ` Number of baths 41_-__ Lot size . % !--r ------ Water ✓1 w, Supply:. Public system Commu�nitY system ❑ Private ❑ Depth to Water Table --------- ft- ------ Character of soil to a depfh of 3 feet:- Sand ❑ Gravel ❑ Sandy Loam Previous Application Made: Yes No Clay Loam E] 'y ❑ Adobe ❑ Hardpan ❑ ❑ New Construction: Yes �o ElFHA/VA: Yes No 0 0. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from neo est well" o_""_ Distance f om foundation____ No. of compartments_-- Size_. lrt Materia"- _ ��_ O T _.Liquid depth- Ca Distanc from - ------ .._ P ff p ----- Disposal F' Id.. Number of Inesearest eli_�I!:® Distance from foundation___fV... "_..Distance to nearest lot line b:of each line------ _`.. �� Width of french------- .`!- Type of fiftor materiaL�� --_--- Depth of filter material____. _ --__"Total length_'___ p See- page pit: Distance to nearest well---'-----_--- a ""�" ---- __.__Distance from foundation____________ _____. Number of pits---------------- " -Lining material__- - Disfance•to nearest lot line----------------- Cesspool: Size: Diameter------------------------Depth----------..----------- Cesspool; Distance from nearest well_,___--___.___---Distance from foundation------------------- Lining materiaf____________-________ ❑ Size: Diameter------- ------- -- -----------------Depth-,- -------.---=-• I -------------- - - Liquid Capacity- --------------------------gals Privy; Distance from nearest well__ _ � "- - - Disfance from'nearest buildin ❑ Distance-to nearest lot line--- ---= --- ---=-- '=" - 9------------------------------ -------- --- ---- Remodeling and/or repairing (describe):--------` ---- K ------------------ -------------------------- ----- ----------- 1 --- ----- ----- - -•--- -- -- - - - -- ------------- --- ------ •----- - - ---- ^ I hereby certify that-1 have-prepared this application and'that the work will be done in accordance wifh San Joaquin County ordinances, State laws, and les and regulations of the, an Joaquin Local alth D'stric+, (Signed)-- ----------------- - - "- ---- -- HCl -- -- By: _ ----------------- on - ---------------------------•- = (Title)---a ' r tractor} (Plot plan, showing size off location of system in relation to wells; buildings, etc., can he placed on revers ide). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ".- REVIEWED BY -- -------- --------------------------- DATE BUILDING PERMIT ISSUED---------------------- - _ DATE-- ----- --- ------ ---- - r ------- DATE_- Alterations and/or recommendations:___ I --------------- --------•---•----• •-------•"-------"-----------•----_-----•---------- --------------------------------------------------------- --------- --- ------------------ -------- ------------ FINAL INSPECTION BY: Date .- --------- - ��---=--��--- -- -� ---------- -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT ` i30 South American-Street 3oD Wes} Oak Street132 S � k ycamore Street, 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M , RevisoG 1-57 F.P.CO.