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C -APPLICATION FOR SANITATION PERMIT Permit No. V (Complete in Duplicate) Date Issued ------------- Application is hereby made to the San Joaquin LocaI Health District for 'a permit to construct and install the work herein described. This application is made in compliance with County Ordinance N 549 LOCATION_ ------------------ -- --- ------------------ ----------------- --------- JOB ADDRESS AN &-------- Owner's Name 4--- -- ----- ------------------------------- Phone----------------------------- Address hone------------------------------------ 0Z)Ir_� - ---------------------------------r --------- Address-,1 Y ------- ------------------------------------------------I---------------------------------------------------- Contractor's Name--------------------------- --------------------------------------- Phone-/_* Q S� Installation will serve: Residence El Apartment House El Commercial [] Trailer Court ❑ Motel E] Other Number of living units:- Number of bedrooms J_ Number of baths zP_ Lot size --------- Water Supply: Public.system E] Community system El Private U?`15epth to-Water Table _/__ ft. Character of soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam E] Clay Loam [] Clay [] Adobe Previous Application Made: Yes E] No 9---N-ew Construction: Yes E] No Rj-'FHA/VA: Yes.D No TYPE OF'INSTALLATION 'AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) e ' Tank: Distance from nearest well-------- -.----,Distane-�-e-f�oen-fouridation----:--------------Material------------------------------------------------- I No. of c;ompartments--------------------------Size------------------------ ......Liquid clepth--------------------------Capacity----------------------- 15.p a Field: Distance from nearest well----- -----------Distance from foundation--------------------Distance to nearest lot line_---_-----_--. Number ine------------_--- Number of lines----------------------- ---------t__Lenqth'of,-each line------------------------------Width of trench----------------------------------- Type rench------------------ ---------------- Type of filter material------------- -----------Depth of filter material-----------------------Total length--------.-----------------------------_.- Seepage Distance to nearest we�l_/10_4---------Distanc ro i fo r vnCia tion----J to nearest lot line__�._/---- Number of pits----/--------------Lining material--- _bC_4_tSize: Diameter___,?,_3...........Depth----�S:.- Distance 'from nearest well------------------Distance from foundation--------------------Lining! material_.-----__-.-----.-----------:-------. El Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity---------------------------;gals. I 1 .1 k, Privy: Distance from nearest well-------------------------------------------------Dista'ce`from.nearest building----------.------_.....-__- ------. ❑ Distance uilding---------------------------------------- Distance to nearest-lot line----------------------- ----------------------------- Remodeling and ----------------------------------------------------------- /or repalring (describe):--------------------------------------------------------------------I----------------_- -------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ -------------------------------------_------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- ------------------------------------- ---------------------------------------------- -------------------------------------------------------------------------------------_------------------------------------------------- I hereby.. rfi that I have prepared this application and that the work will[be done in accordance with San.Joaquin County ordinances, S a e I s, andrulesd-re, ulations of the San Joaquin Local Health District. [Signed}------------ ----------------------------------- --- --------------- (Owner and/or Contractor) 4f-------- --------- ------------------- ---------------------------------- By:-------------------_----_--- --------- ------- I ---------- (Plot plan, showing size of lot, location of system in relation t�nlls. buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------ -------------------- -------------------------------------------------------- DATE-----4--------------------------------------------------- REVIEWEDBY--------------------------------------------- ---------- -------I------ --- DATE BUILDING PERMIT ISSUED------------------------__------------ ----------- ---------------------------------------- -- ------------------------------------- ------------ ----------------- k Alterationsand/or recommendaf ions:------------------------------------------------------------------------------------------------------------------- --_----------------- ------- ---- -- - -- ------- ----- ---- -- ----& ------------------------------------------ ----------- -------- - - - ----- --1!-C-1---------------------------------- -------------e---- - ------- - --- -------------I- ----------------------------------------------------------------------------------------------- ---------------------------- -----------------------(3 - ----------------------------------- ------------------------------------------------------------------------------- -- ---- ------------------------- ------------------------------------------------------------------ FINAL INSPECTION BY::----- �/1��, ------- -- - -------- Date..-r-- - ----/- ---- -- --- ---------------------------------------- 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 Revisect 1-57 F.R.CO.