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een V 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 CATION U� �" "``��--•--��--°''�-------------------- - ---------- Owner's Name------ 2--•--- �1y' '� .�_�one €1_ l Address--------- .- - -T--10- .--------------------------------------------------------------------------------- --- i Contractor's Name--- r �----------------------------------------------------------------------------- Phone---------------------------------- installation -J---------installation will serve: Residence ❑ Apartment House ❑ CommercialK. Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths ________ Lot size ------- Water SuppI • Publics stem 9-1 Community system ❑ Private Depth to Water Table ---- ft. ft. .�; Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam El Clay ❑ AdobeZB�,,Hardpan ❑ Previous Application Made: Yes ❑ No,'K New Construction: Yes No ❑ FHA/VA: Yes ❑ NoX i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__�r��Distance fro foundation_____1_Q_.---_-_.MaterCj_ ��A _ _ . __________ ____No. of compartments_--'fir--------------5ize _ji - -_.__Liquid depth------ t Disposal Field: Distance from nearest wall---�_VLys_sDistance from foundation-----L_Ia---------Distance to nearest lotinjp------- Number of lines------- __ . ____ ______L th f each line____.. Width of trench. ---------------- Type of filter material-- [w# iter material_-___j--- -----------Total length--------- ------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_______________ \{� ❑ Number of pits.---------'-----------Lining material-----------------------Size: Diameter---=-------.------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation- __--_-__._._.__.Lining,material___________________.____________.___ Size: Diameter----_-y )----------.-�___'______________------- - --------------Distance from nearest building-_------------------------ ------------Dept h----------------------------------------------------Liquid Capacity----------------------------gals . Privy: Distance from nearest well__ -----.----.----- Distance to nearest lot-line ----------------------`-------------------•---- � -----------`='--------•------- --- -------- ac Remo g c or repairing ascribe):- d----- '�I � ------------------------- -- - ----�-----"`----------------------------------- ----------------------------------- ------------------------------------------------------------------•-----------------------------'----------------=--- ------- r 4 I hereby certify that I have prepared this application and that the work will be done in accordance with Sah Joaquin County ordinances, State laws, and rules regulations of the San Joaquin Local Health District. ; (Signed) .'* -------------------- ------------------------------------------------------------------ --------(Owner and/or Contractor) By:-------------------------------- ----------------------------------------------------------------------`----------------------------(Title)-------------------------------- ------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------- ------ ---------------------- ---------------------------------------- DATE-----------------�,-/-------------------- ----------------- REVIEWEDBY----:--f---------------------------------------- -- --------------------- ---- - ------------------------------------ DATE_---------- ! ir------------------------------------ BUILDING PERMIT ISSUED--------------------------- -� -- ------------------- DATE -- ------ - -._ Alterations and/or recommendations:------------_._.__ _----__----------------------------...... ----------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- ---------•-----------------------•---------------•--- ----------------------------------•------------------------•------ ----------------------------------------------------------------------------------------------------- ----------------------------------------------------- - -- ---------------------------------- -- - FINAL INSPECTION BY:. ---------------------- ----------- ., Date---- +� "� i 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C.'.' Street f Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1-57 F-P.CO.