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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) q 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 LOCATION_ 71�'21 'X-___ 9._ Owner's Namo4'' �� ----------------- ------------------- ---- ---- -------------------------------------. Address-- ----------•---------------------------------------------------------- - ACi---- --------------------------------------------- Contractor's Name '-~ ---------- S-_ ---- --------------------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel A Other ❑ Number of living units. _�__jNumber of bedrooms --"Z___ Number of baths Z-___ Lot size _________________________ ----------------------------------- Water Supply: Public system ❑ Community system ❑ Private A Depth to Water Table _ 4-ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe I& 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----lj�F----Distance from foundation____At-P _.___.Distance to nearest lot line._s~�_-_____ 'I Number of lines----------------/-----------------Length of each line-----------'�----------- -Width of french------- - ----------------___-- Type of filter material---Tk__o-f_ 1�------Depth of filter material___rg it------____Total length__-- ----------------------------- Seepage --- _____-___________-_Seepage Pit: Distance fo nearest well----/_06'______----Distance from foundation__ __I------Distance to nearest lot line_______._ Number of pits--J________________Lining material__/ 2C' _____Size: Diameter___��_4------___.Depth_.-_. 3----------------------- Cesspool: -J--_____._-_ _ , Cesspool: Distance from nearest well-----------------Distance from foundation_______-----_ ' -- Lining material--------- -------------------------- Size: ---- ----------Depth---------------------------------- -----------------Li uid Ca acit als. Priv Distance from nearest well q Capacity 9 Diameter----------------- ----- y' ---------------------------------------- --Distance from nearest building--------------------------------- ❑ Distance to nearest lot line---------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------ ----------------------------------------------------------------------- ------------------------------- ---------------•----------------------------------- --------------------------------------------------------------------------------------------------"----------------- ----- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----------- ------------------ 14,- ;-- ----`— �� - --o------------------------------------- __ _ caner and/or Contractor) BY: - ... 41 ------------------------------- ------(Title)-------�J— ----------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can belaced on reverse side). e ) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -- BY__-'TR0 `-- ------------- ---------------------------------------- DATE---------q REVIEW - � _ �--�- ------------------ BUILD --------------- BUILDfNGPERMIT ISSUED ------- ------------- ---- ------------------- - --------------------------------- DATE---------------------•--------------- -------f--------------------------------------------------------------------- ---------------- DATE------- Alterations and/or recommendations:-------- --------------------------------- ------------------------------------------ ---------------- --------i---------- _ Tf+.---------------- ---- --- - = -"------------ - --------- -------------------- -------- -•-•----- f FINAL INSP 6Pd ------ Date----------- — -------------- --- -S ------------------------- 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 , Revised 1.57 F.P.CO.