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APPLICATION FOR SANITATION PERMIT Permit No. 2 ® (Complete in Duplicate) Date Issued /.3 Application Application is hereby made to the San Joaquin Local Health District for a permit to con-struct and install the work herein described. his application: is made in compliance with County Ordinance No, 549. JOB ADDRESS AND LOCATION------=Z -Z---- -• ---------- ---- ---------- Owner's Name---------- -�-'v1.._�1-- ` ------��-'��,..' - ,1 ------ Phone-.�``-- ---- Address-----------•-----•---- •----- -------------- Contractor's Name_---- _-�QGVr ----------------------------------- ----- Phone _-. -- ------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ElOt�l er El Number of living units: ------------------------------- ---t--- Number of bedrooms ---I--. Number of�baths ---I--- Lot size �_ � � Water Su ply. Public system ❑ Community system ❑ Private epfih to Water Table - ft. Character of soil to a depth of 3 feet: Sand ❑ " Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑` No New Construction: Yes R 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 Ta k: Distance from nearest well------------- _Dista rice from foundation--------------------Material ----------------------------------------------- No. of compartments---------- ----------Size--------------------------------Liquid depth------------ ---------Capacity------------• -------- Disposal Distance from nearest well------------------D'stance from foundation--------------------Distance to nearest lot line-___---_----_--- Number of lines-----------------------------------Lngth of each line------------------------------Width of trench---------------- r Type of filter material---------------- Depth of filter - ------ f------- er ma -----_----------- ---Total length----------- ----------- -----•--- Seepage it: Distance to nearestell_-+!------------Distance from foundation--- "' f I ��--••------.Distal a to nearest lot line-_------- Number of pits------------- ------Lining material---U-1t,I -----Size: ----- -..Depth----- f� ------------- - Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-__---__-----------_ Size: Diameter----- ------------ ------. ---- ------------ apacy--------------------- ------Depth----------------------------------- Liquid Cit ------gals. ,J Distance from nearest well---------------------------------------------- [` ------------------- ---------------_.-Distance from nearest building Distance to nearest lot line_______________________ % Remadelin and/or irin describ(describgL-------------------------- or - ---------_�" - n l . g ----- ----- ------- ---- g {�� ------ ----------------------- ---------------------- ----- --------------•-- ------- ----------•------------•----------------------------- ----------------------------------------------- ---------- ----------------- -------•-----•-------------------•--------•------•----------------------------------------------------------- - ------------------- - - - -- r ! hereby certify that I have prepared this application and that the work will be done in accordance with San oaquin County ordinance tate laws, and rules and regulations of the San Joaquin Local Health District. Sr ned f # .g - -------------------------------- (Owner an tra r ITitle] _ _. " (Plot plan, showing size of 1,t location of system in relation to wells- buildings, etc., can be placed on reve a e). t i R DEPARTME T USE ONLY APPLICATION ACCEPTED BY----- --f- --------- -- - ------------- DATE--- - - -y -I REVIEWED BY ---------------------------------------------- ---------------------------- DATE_ BUILDING PERMIT ISSUED------------------------------------------------------ - 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-9-2 M , Revised 1.57 F-P,CO- f