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h APPLICATION FOR SANITATION PERMIT Permit No. t (Complefe in Duplicate) �/ t Data Issued �_S - Application is hereby madeto 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 'ATI L - < ------ l� •------- �`---- --------------------------------------------------------------------------------------- Owner's Name_ ___ _ _______ Phone----• ----------------------------- Address_._...----�� --- Contractor's Name-------------- � i'l.� -------------•--- Phone----------------------------------- Installation will serve: Residences/ � El partment House Commercial Trailer Court Motel Other _/__ ❑ j Number of living units: ___ Number of bedrooms Number of baths __�__ Lot size _� ,/ _1-- __ _________________________ ' Water Supply: Public system ommunity system ❑ Private ❑ Depth to Wafer Table Character of soil to a depth of 3 feet: Sand ❑ - Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No PT�New Construction: Yes [ No ❑ . FHA/VA: Yes ❑ No P-'�" TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 240 feet.) Septi ank: Distance from nearest well-----------------Distance from foundation----.----------------Material---------------------------------------________- ts90 No. of compartments------- ----- -----------Size-------------------------------- - Liquid depth-------- - --------------Capacity----------------------- Field: ------ --- ------- Field: Distance from nearest well-----------------Distance from foundation_________________Distance to nearest lot line_________________ Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------------------------ Type -------- ____----.- Type of filter material_________________________Depth of filter material__________--_---¢.____Total length_____________________ �� l Seepage P' : Distance to nearest well_______ _________Distance fr fo dation____ ..___ ,,��_�•.l�t �e to nearest lot line___________.. Number of pits.._.__/_--- ________Lining material--_-�' _______Size: Diameter__ ._._______.Depth___ ____________.___ Cesspool: Distance from nearest well_________________Distance from foundation Cesspool: material___________________________,:______ ❑ Size: Diameter--------------------------------- Depth----------- -,----.--------------------------------Liquid Capacity------------------------gals. ance rom nearest well________________________________________________Distance from nearest building_-------------__________________________- Privy: Dist ❑ Distance to nearest lot line------------- i------------------- Remodeling and/or repairing (describe)------------------- - - -- -y--------- --•----- ---------------------- ----------- ------ ---------- - - ---------- ------------------------ -------. -- � •--------------------•----------------- - -- --- - - -- �{ ------------------------------------------------------------------------------------------ I 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 egulations of t e San Joaquin Local Health District. ------------------ --- ----�---- ---- ---------------------------------------------------- ------- (Signed) Contractor) By:---------------- -• • .. ------'-----------------------(Title)-----� K-------------------- ----------------------------- ------------ (Plot plan, showing size of lot, location stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY i ------------------------------------------------------- DATE ---------------- APPLICATION ACCEPTED BY---_-__-' - ---------------------- - --- ------ --- REVIEWEDBY------- -----=-------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------• DATE-------------------------------------------------------------- Alterationsand/or recommendations---------------------------------------------------------••-------------------------------------------------------------------•----------------------------- ------------- ti -----= i` ------------ -- ` ---- ---- ----------------------------------------- ---------•----------------------------------------------------------------------------------------------------------------•------------------------------------------------ FINAL INSPECTION BY:-------►�'4 -----------•--------------- Date `../- F SAN JOAQUIN LOCAL HEALTH DISTRICT k 130 South American Street 300 Wes+ Oak Street; - 132 Sycamore Street 814 North frau+ S+ock+on, California Lodi, California _ *' Manteca, California Tracy, California ES-9-2M Revisea }_57 F.P.CO. ��. f