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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) - Date Issued _____ /51 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 Count Ordinance No. 549. 777-5` f_ ,Ya<�Ftp Z.6 t JOB ADDRESS AND LOC N------------- -- - - - -- ------------------------ Owner's Name--------------- p-- - - --fir--------------- -- ---------- ------ ---- ---- ------ -. Phone------------------------------------ Address---------- --•----------------- -- Contractor's Name--------------- ------------- --------- ---------- Phone-- Installation will serve: Residence ❑ Apartment House [] Commercia7railer Court ❑ Motel ❑ Other ❑ Number of living units: __ ____ Number of bedrooms _:______ Number of the -------- Lot size ____________________________________________________________ Water Supply: Public system Community system ❑ Private E] Depth to Water Table i7ft. k Character of soil to a depth f feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cla Loam E] Clay E] Adobe Hardpan F]Previous Application Made: Yes E] Nox New Construction: Yes [] No FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATfONS: C (Nonseptic tank or cesspool permitted if public sewer is available within 200 feet.) Sepf T a Distance from nearest well_________________Distance from foundation--------------------Material---------------------------- .__________.________. x No. of compartments--------------------------Size--------------------------------Liquid depth---------- ----- --------.Capacity-••-------------------- l� is� -11 DDistance from nearest weft___ _ _ -_ '� _ .__.._____Distance from foundation_________________ .Distance to nearest lot line_-_____________ j� Number of lines-----------------------------------Length of each line------------------------------Width oftrench----------------------------------- N 4 Type of filter material_______ __ _______,____Depth of filter material-----------------------Total length----------------------------------- _ fSee a e Pit: Distance to nearest well___ -O/.015:__-Distance from foundation_-S--------------Distance to nearest lot line-----9/ - Number of pits-----/--------------Lining material---�C�__Size: Diameter__. �-- Depth_-_�f�---____________ Cesssspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material--------- ------------------------- ❑ Size: Diameter---- ---------------------------------Depth--------------------------------------------------._Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------------------- f ❑ Distance to nearest lot line------------------------------- -------------------------------------- r/ Remodeling and/or repairing {describe:- ----------- ------------------- ----------------------•--- S----- - ----- -••. ------------------------------------ ----------------------------------•----------------------•------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepare is ap licatio that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an a 1 oft 4,S Joaquin Local Health District. d (Signed) _ /F --- - wrier and/or Contractor) .� �Q Sy:---------------------------------------------------------------------- ---- - ----- -------------------------(Title)------------- ----------- (Plot plan, showing size of lot, location of system in relation to wells 'dings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- DATE--------------- b REVIEWEDBY--------------------------------------- -- - --------------------------------------------------------------- DATE ------1� BUILDING PERMIT ISSUED----_----------------- --------------------------------------------------------------- DATE Alterations and/or recommendations--------------------------------------------- ---------------------------------------------------------------•------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------•--•--------------------------------------------------------- ---------------------- ------------------------------------•----------------- ------------------------------------------------------------------------------------ ---•------------------------------------------------------ FINAL INSPECTION BY:------ Date-----m "" "' ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revisea 1.57 FRCO.