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.. APPLICATION FOR SANITATION PERMIT Permit No. ......... IV - � (Complete in Duplicate) Date Issued Application is hereby made to ,Ae San Joaquin Local Health District for a permit to cons u all the work herein described. This application is made in compliance with County Ordinance No. 544. r JOB ADDRESS AND LOCATION______ _ _ Owner's Name------------- ----------:- -- - ----------------------- ------ Phone----------------- -------- -------------- Address--------------------------------- ------------------------------------ --------------------- ------------------- Contractor's Name ------------------------------------------------------------------------------------------ Phone--------------- Installation -------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ Number of bedrooms__ Number of baths ____ __ Lot size ___ -- __ ___________________________ Wafer Supply: Public system JRL.., Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loan- Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made: Yes ❑ No Z New Construction: Yes 16.,Vo ❑ PHA/VA: Yes E] 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 wello-W Distance from foundation -/O__;------- Material-oo, -____ , ) No. of compartments-a�.-------___._..----Size__-- q p ----___--Capacity Ab i " `Disposal Field: Distance from nearest well_ Lf1-Distance from foundation___/.6_ _--__.Distance to nearest lot line______ Number of lines_�____�____ '___ _.---_--_Length of each line------�C�_d______-------Width of trench.__ __.------.-- -- ------------ Type of filter material__ ._ _ Depth of filter material-- �_ _-----Total length---------Jd�.�______-•--_------ � Seepage Pit: Distance to nearest well-;ffr_C<(J _Distance from foua ion_____- .�__.Distance to nearest lot Sine___ X--"._ Number of pits__ -__-_--______-Lining material_ _ e: Dia mefer__(jX__-6,U..Depth-_._�_ -------------I Cv Cesspool: Distance from nearest well________________Distance fro foundation--------------------Lining material------------------------- \- ❑ Size: Diameter ----------------- ---------------Depth--------------------------------------------------Liquid Capacity----------------------------gals. f�\ Privy: Distance from nearest well-------------------------------^------------------Distance-from nearest, building----------------•-----------------------_ ❑ Distance to nearest lot line___.--._ "___----__�_',__.:___--__^-_ --------------------------------- ------------------ ---------------- Remodeling and/or repairing (describe):._. _ --•---------------•-------------------------:-------------------------------- I} ----------------------------------------------•----------------------------------------- -- --- --------------------------•---------------------------•---•-------------•------------------------------------------------------------------- ----------------------------------- --------------------------i-------------------------------- •------------------------------------------------------------------------------------------------------------------------- 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 regulations of the San Joaquin Local Health District. r (Signed) --------------------- -----------------------------------------------------------------------------------------(Owner and/or Contractor) BYI- -----------------------------------------------------------------------------------(Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ------ ------------------------------------------------ DATE - ®� S ----- REVIEWED BY t - -- - --- DATE- - BUILDINGPERMIT ISSUED---------------- -------- ---------------- ------ ---------- - - --------------------------------- DATE ' r Altera#ions and/or reco+nmandationsa--------------------- - ----- ----------- -----•----•-•--------- - 1 /-�r----- -------- ----------------•------------------------------- ---..------------------------------------------------------------------- - ------------------------------------------------ --------------- --------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------- / C FINAL INSPECTION BY: g?O Date C3_ ` V SAN JIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Streef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M , Revised 1-57 F-P.CO.