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r� OF APPLICATION FOR SANITATION PERMIT Permit No. ---_--------7-----7 (Complete in Duplicate) Date issued --- Application is herebymadeto the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made-in compliance with County Ordinance No. 549.. JOB ADDRESS AND'` OCATION_:______- ��-_-- -_.-- ��d � ; i. � ` Owner's Name----- 0-� = = � �:_ --- --- - - F._ Phone---.: Address ,fid' ' � � �� ------ - Cont ' ------------- Contractor'' Name-' ---- --- I - _ hone----•-•--------- ----- --- Installation will serve: Residence ❑ Apartmen+ House El CommercialCourt [:] Motel ❑ Other ❑ Number of livingunits: _.f. __ Number of bedrooms _^- -_ Number of baths Lot size __._ a_ _- ______________________ , T Water Supply,' Public system��Community system ❑ Private ❑ ep ater Table loft. Character of soil to ardepth"of 3 feet:, Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ ` Previous Application Made: Yes ❑ No;KI—New Construction: Yes E] NoFHA/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: _ t Distance from nearest well_/-[��% Distance from ffoundation__._f --___.Matenal___..L-_----- ,__._______. .No. of com artments__- --------------Size_ ?__x--u1c --.---Liquid 'depth------- --�---- CaPacsty-------g4P-'V.... Disposal Field:. Distance from nearest well----------'-------Distance from foundation--------------------Distance to nearest lot line________.__-_._.. 0 Number of lines----=-----•----------------------Length of each line------------------------------Width of trench----------------------------------- type of filter material'___.__'------------------Depth of filter material-'_" ,---------------'Total length----------------------------•--.---------- Seepage Pit:. "Distance to nearest well_:/1�_ Sistance.fro foundation_ ..___.Distance to nearest "' w. me � _pi _____; -- ___ g USize: Diameter__".K__3_f {Depth_ _ Cesspool: Distance from'nearest well _.__ _Distance`fr.om.foundation-------------------_Lining material-----------------------.___________ ❑ Size: Diameter_ ----- -------------------- --------------- Depth-------------- -----------=-- ------------ . -Liquid Capacity------------------------- -ga Privy: �'. , Distance:from nearest well--------------------------------------------- -_Distance from nearest building_'_______________________________________ ❑ ._ ---= .-,__---=------=------------------------------------- Distance to nearest lot- .. _.__.-------------- Remodeling and/or repairing (describe)-----------------------------------=-==----------------`---------------------------------------------=-.-=-----=------------ . --------- --------- - - ---- ----- 4 ---------- I hereby certify+hat I have prepared this application and that the work will be done in accordance-with San Joaquin County ` ordinances, State I and rules and regulations of the San Joaquin Local-Health District. (Sign, �Y { ( n er and/or Con ractorl ---------- ------------------------ ------- --------------------- (Title) --------------------------------------------- ---- ------i-----�------------------------------ (Plot plan, s wing size of lot, location of system in.relation to-wells, buildings, etc., can be placed on reverse side). FOR-DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------- --- ----------------- DATE------ __ -------------------------------------------- REVIEWEDBY------ = - ----------------- --=--'----------- ------------------------------ `-----"--------- DATE-------------- - BUILDING PERMIT ISSUED_------•--=-------`--------•- -- -- - -----"---i-------=--------------- ---- DATE--------- ----- , -- - Alterations and/or recommendations:-------- ----•-------•-= ' x f ---- -- --- --- - ----- - ... � -- --- _ -- - -- - -- - FINAL INSPI=CTION,.,BY:. = - . w, --- Date i 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 E5-9-2M Revised 1.57 F_p.CO.