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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 JOB ADDRESS AND LOCATION- $ ... - - ----------- Owner's Name RN, � � PhoneAddress-------------------------------------- a -7-:Z Contractor's Name---------------------------------- Phone. Installation will serve: Residence Q partment House ❑ Commercial E] Trailer Court E] Mot ❑ her F1 Number of living units: I____ Number of bedrooms -Number of baths -1--- Lot size -_-_- -- / !----------------------------- Water Supply: Public.system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand �avel ❑ 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: _ a (No septic tank.or.cesspool permitted if public sewer is available within 200 feet.)' Septic Tank: Distance from nearest well---,�A.......Distan//c�e fr m u dation_--1 -----.--_.Ma ejial----_ - No. of compartments-------�1-----------Size_CA_ - -._--Liquid depFh-- -----------------Capacity. ..... - 11 Number of lines____-. -fir -- -- ---Length of each line------'j --- ---_r-_---.Width of trent -- Disposal Field: Distance from nearest well_�rsD_'_ Distance from foundation-/-K- - ---Distance—t�o nearest of ine__-- Type of filter material-_, i_)2 -Depth of filter material----- - --------Total length----------- -41--_-.- ----_-_--------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-----------------------Distance to nearest lot ----------------- Ll Number of pits----------------------Lining material-----------------------Size: Diameter----------. --------.-.Depth----------------------.---------- Cesspool: - --- Cesspool: Distance from nearest well:--:-------------Distance from foundation--------------------Lining material----------.-----------------.---------. ' ❑ Size: Diameter----- --------------------------------Depth------------------------------ ------ --------------Liquid Capacity-----------------------------gals. __Distance from nearest building Privy: Distance from nearest well-------------------------------------------- g----------r----------------'--•---------- ❑ Distance to nearest lot line---------------------------------------------- -•----------------------------------------------------------------------------"--------- Remodeiing and/or repairing (describe):------ -------------.---------------------•----------------------------------------------------•-------------------- ---------••--------------------------------•---------------------•-----------•--=------------------------=-------------------------------------------------------=---------------------------------------------------------- ------------------•-------•-- --------------------------•----------=------........--------...-.._•---•---------------------------••----•-------••-----•-.----- - -------------------- ------------------------------------------------•------------------------------------•------------------r-------------------•-------=------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and r les and regul ions of the San Joaquin Local Health District. s d(Signed)-- - -- .•'�=--`-- t��-------- ---- - - -�- .•-•-'------------------------------------------------------------(Owner and/or Contractor] B .---------- - -------------------------- --------'---------------------------_------ -------------- ----- ( e) _. : (Plot pi n, showing size of-"lot 10-c—ationTof system in.relation to wells, buildings, etc., can be placed on reverse side). ' FOR EP•ARTME USE O Y ` APPLICATION ACCEPTED BY--- ' DATE---- ------------- REVIEWEDBY-------------------------------------------- ---------------------------------------------------•---------------------------- DATE --------------------------- -- BUILDINGPERMIT ISSUED--------- -------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:---------------------------------------------------------------------------------------------------- ---------- ----------------------------------- ------------------------------------------------7---------------------------- - -------•-•---------------------------------------------------------------------------------------------------------------------------------------------------------------------•-----•-------------•----••----------------•--------------------------------•--- ---------------------------------------------- ----•------------------------------------------------------------•------------------------------------------•--------------------------------------------•------------.-- ------------------------------------------------------- ---•--------------------------------------.----------------------------- ---------------•---------------------•------•------------------------------------------- r FINAL INSPECTION BY: = --------------- Date == SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street - 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tray, California ES-9-2M Revisea 1.57 F.P.CO.