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" APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) + 3p 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 Countyprdinance No. 549. JOB ADDRESS AND, LOC�TIQN___ - .- --: ------------------------------ - -------------------------------------=-------------------------------------------------------------------- Owner's Name------- -" `'e ----------•- ---- - - ------------=`------- ----- ---------------------. Phone -- �Adclress------------ ----------------------------- 'r Contractor's Name ---------------• -------------------------------------------------=--------------------------------==------------- ---- -Phone---- F. Installation will serve: Residence ,r Apartment House ❑ Commercial F] Trailer 'W V. Motel ❑ Other ❑ Number of living units: __0____ Number of bedrooms Number o baths p-____ Lot size __1__( - {_ ____________________________ Water Supply: Public system [-] Community system F1 Private epth to Water Table -------- ft. Character of soil to a depth of.3 feet: Sand ❑ Gravel ❑ Sandy Loam 0- Clay Loam ❑ Clay ❑ Adobe.Hardpan ❑ Previous Application-Made: Yes ❑ No Y", New Construction: Yes ►"No ❑ FHA/VA. Yes ❑ No 57 TYPE OF INSTALLATION AND SPECIFICATIONS: s F (No septic tank or`cesspool permitted ifuklic sewer is available within 200 fee4- � r . Septic Tank: Distance from nearest well____ ista e froom{founation_l�-______________Materi I__ ..- _____. l No. of compartments_ t Size__ '_f KIR_I� -.___Li uid e th__ __________ _ LCa acit � L�_Q_-I.___ t t ------ Dispo�al Field: Distance from nearest w I�r Distance from foundatkon`L/____._!_____. istance±to nearest Iotli�Tt_ _Yi'Lt-�r/� Number of lines___._______ ___________Length of each li ______________ ___ _�f e�Vidth of trench--------_._1�_f_,,_�____t____________ Type of filter materi � -Deptl'i of filter material_______ _.__-____.Total length_____-_.---_ I Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_______.______.__ ❑ Number of pits--- --Lining material-----------------------Size: Diameter-± --------------'_.k_{.Dept h----------..--------------------- Cesspool• Distance from nearest weH-----------------Distance from foundation------------------ Lining rnateria}____'__________________________ \f ❑ Size: Diameter---------------------------- ----------Depth_----- ---------------------------------------------Liquid Capacity----------------------------gals. -Privy: Distance from nearest well_______________________,-------------------------Distance from nearest building--------------.________________-_.--___._ ❑ Distance to nearest lot line----------------------------------------------------------------•------ ------------------------------------------------------------------- Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------=--`-------------------------------------- ------------------------------------------------------------------------------•---------------------------------------------•------••-------•----------------------------------------------------------------------------- --------------------------------------------------- ------------------------------- ----------------------------- --------------------------------------------------------------------------------------------------------- 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. (Signed) _____________________________Owner and or Contractor ---------- By:------------------------------------------------ -----------------------------------------------------------------------------------(Title)-------------------------------------- ------ h (Plot plan, showing size of lot, location of system in,relation to wells, buildings, etc., can be placed on reverse side). - r---� FOR DEPARTMENT USE ONLY -A 41 APPLICATION ACCEPTED BY _ DATE ------------------------------------------------------ REVIEWED ----------•---5------------------------------------ + REVIEWEDBY------------------------------ ---------------------•----------------------------------------------------------- DATE- --------------------------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE____'9- � Alfiera 'ons and/or � recmend tions-----.--n- --- - -- ��.-._ - . -. .-____ ---_._P ___ - - _� - _� � -_�M _ , ---------------------- 'A' ----------------------- �- V_ ----- --- ---- � e�---------- • .��.--------- --- ----- ---- ------- - Z 4--- - --� - / - - Date-- FINAL INSPECTION BY:. --------------------- z 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-9-2M , Revised 1-57 FY CO. �.