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APPLICATION FOR SANITATION PERMIT Permit No. ........................ (Complete in Duplicate) /D/� /_ _ R Date Issued --- I` ¢' Application is hereby made tos the San Joaquin Loeal Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. . - rr � gg ---- JOB ADDRESS AND LOCATION_ 1P` 'Y .�r 'Y"___-_ __ __-•----_______________ -�---- --------- f Owner's • -- !? ------_-•------•-----•--------------------------------------------------------------------------- Phone.-----------------. --------------- Address_-•-----•-•--'--0--�--•---•--:... � .... --•--••------------._ --- ------f ---- ..........��------ ------------------------------ Contractor's ---------------- Installation 1 Name `--------------`----------------••------------------------------ ---------------------------------------------------------- Phone----_--------------------------- Installation will serve: Residence h Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____I_--Number of bedrooms __I____ Number of baths .__4____ Lot size ................... Water Supply: Public system "Community system ❑ Private ❑ Depth to Water Table GO, ft. " Character of soil to a depth of 3 feet: Sand [3 Gravel ❑ Sandy Loam V] Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes. J "No ❑ New Construction: Yes {XJ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tan or cessiool permittedif public sewer is available within 200 feet. ) ancmest well 1v�__--Distance from foundation_ k _1 � �_________,Septic Tank: Diste onear _ � No. , of compartments--.____�„--------- 7 _.._,_..Liquid depth---- ------------'__--_Capacify.. ±-----__ ---Size._..--�----- ` - Disposal Field: Distance from nearest well-1-gMs ---_.Distance from foundation____ _____,___:.Distance to nearest lot line-------------- E Number of lines___`__✓_i____ _Length of each line__,?q`____ Width of trench---XY-------------------- '._ Type of filter material-A_ _ m _ _.___Depth of filter material:' _ :__ ________Total length__-_.1p------------------------------ ? Seepage Pit: Distance to nearest well------- --------------Distance from foundation.................".Distance to nearest lot line______.______.._ j ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth--------------------------------- Cess'pool: Distance from nearest well_______________`Distance from foundation---------------.-----Lining material-__________-_.____._ ---------------- ❑ Size: Diameter-------------------------: 4---------Depth-----------------=----------------------------------Liquid Capacity ------r--------------------gals. Privy: Distance from nearest well____-_-_,--------------------.--------------------Distance from nearest building------------_____--____________________-- ❑ Distance to nearest-lot lire-----------------------------------------=------------------------=--- -------------------------=--- ------------------------------- Remodeling and/or repairing (describe):------ ----------- -------------------------------------I—------------------------------------------------•---=---------------•----•-----•------- , --------------------------------------------------------------------------------=-------------------------------------------------------------------•-----•------------------------••---------------•------------------------ -------------------------------------------------------- ,-----------------------------------------•- -------------------------------•-------------=---- � - I hereby certify that l 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. t ; (Signed)-----de--- - ------------------ -------------- ----------------------------------------------------------------------.(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). i FOR DEPARTMENT USE ONLY - 3 APPLICATION ACCEPTED BY__ �l � _.____-_ ----------------- DATE---fd---��- `- -. ----- - --- ---- REVIEWEDBY--------------------------------------------- ----------------------------------- ------------ -_---------------------------- DATE-------------------------------•----------------- ---------- BUILDING PERMIT ISSUED----------------------- -------------------- -------------------------------------------------------- DATE-------------------------------------------------- - - Alterations and/or recommendations______________________ _ �+----_------ A -� --------------- `-:- _ ----------- - _. ._ -------------------- ------------------------------------ --•------------------- --- -------------- --- FINAL INSPECTION BY:.; --------------- Date-- ---------------------tl-- ~ SAN JOAQUIN LOCAL HEALTH DISTRICT 3 130 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 F.P,CO.