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APPLICATION C rtFOR SANITATION PERMITvV erpit No. .___l�_ _ (Complete Dphtatel Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to const uct and install th work herein described. This application is made in compliance with County Ordinance o. 549.'S C��`�':. .�- I JOB ADDRESS AND LOC u �� -- TION -- ---7_ '_---- „ --__ ------- ---- Owners Nam ---- ---_ •----- ----------------------------------------- Phone- Address--------- Contractor's - ---��- ---9---6---- ---- Name"---- ---- ------------------------------------------------------------- Phone.-,- Installation will serve: Residence E] Apartment House F] Commercial [-] Trailer Court ❑ Motel ❑ Other i Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ---__________________ ---------------------- Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Tableft. t Character of soil to a depth of 3 feet: Sand ❑ Gravel E❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe [Hardpan ❑ Previous Application Made: Yes [Po ❑ 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 fee+.) J IW&Tank: Distance from nearest well_;--------------Distance from foundation--_-_-_-- -_-_-.Material------.------"----_------------ ------------ No. of compartments----------- ------Size--------------------------------Liquid depth-------------- - Capacity a -- --•-------------------- o field: Distance from nearest well._:----_______-Distance from foundation--------------------Distance to nearest lot line-----_------_---. Number of lines-1---------------------------------Length of each fine------------------------------Width of french.-----------------------"----- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest wel .hd_�-------Distanc om cundation__...7 -..Distance to nearest lot line_______-_ [l� Number of pits--f_ __�__--,Lining material Size: Diame#er-___ Depth----- CesspooE: Distance from nearest well-----------------Distance from foundation-------------------.Lining material--------------------- Li Size: Diameter-- D __.__--_________ -41 - -------------------- ------------ p --------- ------ -------------------.-Liquid Capacity -------------------------gals. I -4Z t Privy: Distance from nearest well--------------------------------------------------Disfance from nearest buildin .� ❑ Distance to nearest lot line-------------------------------- ---------------•----_-_ ------------ ----------------------------- Remodeling and/or repairing (describe):_ _" -- _ --•----- -- t --- ------ ------- ------------------------------------- ------------------- z - --------�--- ----- --- ' 1. f ----- ----------------------- ------------------ - ----- I ereby certify that I have prepared t{iis is and that the work will be done in accordance with San Joaquin County ordinances, Sa laws and rul nd reciulations. 16the San Joa uin Local Health District. V Ili (Signed)(S�9 ”-="---- -------- ------. ---.-------.. --------- _ - --------------------------------------------------- (Owner and/or Contractor{ By:--------------------•- ------------------------------------------------{Title) -- 1- ------------- --•----------- - , (Plat plan, showing size of lot, location of system i elation to wells, buildings, etc., can be placed on reverse side). f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ----------- ----- --------------------------------------------------- - , DATE------ --•---------- ----------- ~- REVIEWEDBY--------------------------------------- - •------ �.- ----- ------`-'�------ -- ---------------------------------- DATE---- ------ ----------------------------------- BUILDING PERMIT ISSUED_ - ------------------------ DATE Alterations and/or recommendations:_ ---•------- -_---------=------ -_ r --- ----41--- -- -- ----- --- ------ - ---------------- --------- _ ry ------ ---------------- - /0 `� ----- - �u,---- FINAL INSPECTION BY:------- -Y v Date .2 -�--o)-d --- �- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strest 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revises 1-57 FY.CO.