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APPLICATION FOR SANITATION PERMIT Permit No. __f.��.�f_••- 1, (Complete in Duplicate) �. UUUU Date Issued ._____ !�Ao 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 LOCATION__ 3j'6' �1 '_ { --------------••---------------------------------- -• ------- Owner's Name------�----- ---- yyyy�� •- -- ----------------- - ------ ---------------- ------ Phone-----------•-----------•----------- Address----••---------•----- - --•----•----------•--------------------------------------------------- Contractor's Name--------- ----------- f ----------- -------- - ---- ------ Phone__.-•---------------- -Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___1___ Number of bedrooms ---I--- Number of baths _-_/___ Lot size ------47�_ _x_/_{a Water Supply: Public system © Communit Y system E] Private ❑ Depth to Water Table _`!'s_ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe J� Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ PHA/VA: Yes ❑ No ❑ 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-----------------Distance from foundation____________________Material ❑ No. of compartments__._-____ ------------------- ---- -------- --Size--------------------------------Liquid depth--------------------------Capacity p fi' --------------- Disposal Field: Distance from nearest well. --------_.Distance from foundation____________________Distance to nearest lot line______.________-. ❑ Number of fines-----------------------------------Length of each )ine------------------------------of filter material------------------ --"----- --.Width of trench -------------- ___A _"" --""""-- �r.� ------Depth of filter material-----------------------Total length------------------------- -------------- Seepage Pit: Distance to nearest well_- . �__-__-Distance from foundation_.3 f __ Number of pits___ __________ ______Lining material__?V- -.Distance to nearest lot line_ �_r-----_ g --------.Size: Diameter__.__'3�_:.--------.Depth---.�--� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.________._______.________ r � ❑ Size: Diameter----- -- ---- ------ ----------Depth----------------------------- Privy: ------ --- ---- - ---- --- --------Liquid Capacity----------------------------gals. PnvY: Distance from nearest well_____________________ -----------------------Distance from nearest buildin ❑ Distance to nearest lot line_ 9 ------------------------------------------------------ Remodeling and/or repairing (describe):--------`---------------------------------------------------------------- ------- ------------------------- ---------------- f ---------•-------------------------------- --------------------------------------------------------L-----------------------------------------------------------------------------------"-------------------------------------------------------------------------- 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. Si ned _______ - --------------------------------------------------------------------------------------------------------- (Owner and/or Contractor) - - (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 APPLICATION ACCEPTED BY__-- ___ ------------- ----------------------- DATE------- REVIEWED BY------------------------------------ ---------------------------------------------------------------------------------------- --- DATE---- --------- -----------------•- BUILDING PERMIT ISSUED-------------------------------------------------------------- -------------------------- ------------------------------------------------------------------------------ E Alterations and/or recommenda+ions:_ __-- ----" ----------------------------- ------------------------ ----------------- - ---------------------------------------------------------------------------------------------------------------------------- ------------- ----------------------- FINAL INSPECT y Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California f ES-9-2M . Revised 1.57 FRCO.