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V/ APPLICATION FOR SANITATION PERMIT Permit No. (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. JOBADDRESS AND LOCATION C ---------------------------------------------------------•----------------------------------------------------- Owner's Name---- ------------ Phone------------------------------------ ,yy� Address �s ,r •:rte[! -------------------------- Contractor's Name---- -- -- ------ 1 " --- -------------------------------------- Phone._-----____--- —5 L--- Installation will serve: Residence [] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [] Number of living units: Number of bedrooms __2__ Number of baths ___/__ Lot size _____ -,(A-79_____________________________ Water Supply: Public system Q Community system ❑ Private ❑ Depth to Water Table 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 ❑ 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 Tank: Distance from nearest well_________________Distance from foundation--------------------Material_________-----_-----___________-________________- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest well-rhsf+C__-_Distance from foundation_df--__________.Distance to nearest lot line---(3y__,____ 14 Number of lines---------L_______________________Length of each line---_-__�®_/------------Width of french---zY-y---_-_-.___-_______ Type of filter material-__-Vv_G�--------Depth of filter material---lff_`__________Tota# length------- _ ________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-._.___________ F] Number of pits----- --Lining material-----------------------Size: Diameter-----------------------Depth---------------._---------------- fist Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material---------------------------._-__-____ G,1 ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------------- _______. ❑ Distance to nearest lot line-----------------------------------------------------------------------•----------------------------------------------------------- - � Remodeling and/or repairing (describe):-------- ---------------------------------------------•---------------------------------------------------------------------------- ------------------- ---- ---------------------------- --------------•-----•-----•-----------------------------------------------------------------------------------•------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la s, and es and regulations of the San Joaquin Local Health District. (Signed)_____ ___ ____________ ______ _ _ ------------------------------------------------------------(Owner and/or Contractor) By: = = -------------------------------------------------------(Title)----- 'C1> --------- -- ----------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- --------- --------/--- ----------------------------------------------------------------- DATE-- --- ---------- --- ------------------------- REVIEWED i3Y- DATE zL{1�-------------------------------- BUILDINGPERMIT ISSUED-..__.----------------------- ---- --------------------------------- ------ ---------------- DATE------------------ ------------------------------------- Alterations and/or recommendations:---------------- ------ ------------------ ------------------------------------------------------------- ---------•------------------------------- --------------------------------------------------•-----------------------------------------------------------------------------------------------------------•--------------------------------------------------•------------ -----•---------------------------- --••---------------•---------------------------------------------------------------•------------------------------------------------------------------------------------------------------ ----------------------------------------------•------------------------------------- ------------------------------------------------- -------------------------------- ------- --------------------------------------------- -----------------------------------•-------------------------------------- ---•-------------------------------------------------------------------1----- ------- --- --------------------------------- ---------------------- FINAL INSPECTION BY:.-------- ------------------------------ Date-------- �-```-f 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-9-21,4 Revised 1-57 FRCO.