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APPLICATION FOR SANITATION PERMIT Permit No.� - a in Duplicate) (Complete P ) 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__.__3_�_____ --------------------------------------- --------------------------------------------------------------- ---- Owner's Name----- - •----- f � ►- Phone ----------------- --------- - ------ - --------------------------------- Add ress----------• -------- � ®�� ti, - Contractor's Name'/'`'` -------------- Phone._"�_._�6�,`+ ----------------- Installation will serve: Residence Apartgent House E❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: ___i--- Number of bedrooms __v_L_ Number of baths _I____ Lot size Water Supply: Public system Q Community system ❑ Private ❑ Depth to Water Table y ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam p Clay Loam p Clay ❑ Aclobem 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 ank: Distance from nearest well_________________ Distance from foundation __________________.Material No. of compartments -------------------------- Size- ------------------------------- Liquid depth ---------------- ---------Caaci P ity ------------------------ ,,Disposal pField. Distance from nearest well --------- Distance from foundat,ion__&_'_-------- Distance to nearest lot line --- •�------_____ Number of lines -i -------_- )---------------------- Length of each line -----_�--------------- -Width of french ---- ------------------- ---- Type of filter mai erial_____i_e�________ Depth of filter material__1r- -- ___________ length Total _____ ____________-____- --------- Seepage Pit: Distance to nearest wak.... t.c -----_Distance from foundation___t_ ____ ___.Distance to nearest lot line ..... 3'_�_____ [� Number of pits__ C- ' ---- Lining material____ p_e,-I --_.Size: Diameter ------ .?3-* s lr :. Depth_ rJr--------------------- Cesspool: Distance from nearest well________________ Distance from foundation ------------------- Lining material-_____ ------------------------------ -'Fl-, Size: Diameter---- --------------------------------- Depth ---------------------------------------------------- Liquid Capacity -- -----------------------gals. Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building ❑ Distance., to nearest lot kne----------------------------------------------------------------------- ------------ - - -------------------------------------------------- Remodeling and/or repairing (describe)____________________ ____-_ ---------------------------------------------------------------I _. w -----------------------------------------------------= - ----------------------------------------------------------------------------------------------------•-------••----------------------•----------------------•------------------------------------------------- ! 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 eind regulations of + e San Joaquin Local Health District. ``^Q�� (Signed) ------------ v-- --- ----- ---- -- - ---- -----:i --_Owner and/or Contractor) By:. ----------------------------------•--------------------•--------------- Title ----- ( ) - ----- ------------------------ (Plot plan, snowing 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_�-__, DATES - M REVIEWEDBY -- --- --•----------------------------------------------------------------------- ------ DATE- ------------------------------------------- BUILDING PERMIT ISSUED____________ i ` ---------------------------------------------------------------•--------------- DATE----- Alterations d/or recommendations:-------------------------------------------------------------------------------------------------------- ----------------------- U-- -----------------------------------------------------•-------•------------------------ -= _ - = _____ __::=::_-_- __ __ ______________________ __________________________________________•----------------------- '' --- ---------------- -------------------------------- - --- - - - - - ------ -----) - - t----------------------- - - �i k � y FINAL INSPECTION 8Y:___ ______ Date----- -- r---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California Lodi, California Manteca, California 814 North "C' Street Tracy, California ES -4-2M , Revfsea 1.57 F.P.CO.