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1 FOR OFFIC U E: APPLICATION FOR SANITATION PERMIT Permit No. ...;ir_ _.1..,�`. ----------------------------------- (Complete----------- ------ - Cmlete in DuDate Issued ---------------- This Permit Expires 1 Year From Date Issued Application-is hereby made to the San.Joaquin Local Health District for a permit to construct and install the work herein described. a This application is made in compliance with County rdina a No. 544. JOB ADDRESS AN LOCATION•-- .. ° -----•--- - ---------•--------------------------- Owner's Name---.---- -- --•--- Phone------------------_ -_---------- ------•-------------------- -------------------------- ` 1 __--•--•---=•-• ------••--------•-•-----•-----------•-----•-- Address-----•------------��-,��------- •---- ---�-- •- -------------�----•--------------•-------••---------••---------- Contractor's Name------------ Phone. Installation will serve:, IResidence [A—Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I---- Number of bedrooms _� Number of baths .__I__- Lot size -----------------• Water Supply: Public system.IF,- Community system ElPrivate [-] Depth to Water Table -- ft. Character of soil,to a depth of 3 feet: Sand ❑ Gravel ElSandy Loam C1Clay Loam C] Clay C] Adobe 2 -14ardpan C] pp y ] [E-14o ❑ No f Previous Application Made: [If es,date__-_______._ _ ._ } No New Construction: Yes FHA/VA: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No.septic tank or cesspool permitted if public sewer is available within•200 feet.) Sept *Tan Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------- .----------- � No. of compartments--------------------------Size---------------- Liquid depth ------Capacity...------------------- Disp sal Field^ Distance from S'nearest well-------_------___.Distance from foundation..----------------..Distance to nearest lot line---------------_ Number of lines Length of each line Width of trench Type of filter material--------------------------Depth of filter material-----------------------Tota l length--------------------.•-------------------- Seepage Rif: Distance to nearest well ` -_-____Distance f om f undation__� -------------Distance to nearest lot line_�fI__--._ Q ----Lining materials ------Size: Diameter____________ _________Depth-- ---.----------- Lk1" Number of pits_____::-�---- -- �.+ i ,t Cesspool: Distance from.nearest well_________________Distance.from foundation___.-_______.______-Lining material._____._-_____._____._-_..________.._. Q ❑ Size: Diameter---------------------------I--------.Depth----•----------------------------------------------Liquid Capacity..........-----------------gals. Privy: Distance from nearest well_____._t_---_._._-------------------------------Distance from nearest building--------.-.--------------------------- .--- ❑ ..Distance to nearest lot line------F-- ------------ --------- -- --------------=-------------•--------------------------------.- ------------------------------------------------ :.. Remodeling and/or repairing (describe) ---------------- --------- -- ---- ------------------------------------'`-----------------------------------=-------------•-----•-------------------•-------•-••---•---------------------•--------------------------------- ---------------- ----- ---- - ---------------------------------- ---- --- ------------------- --------------------------------•------------------ ----------------•••----•------•--------------- -------••----------------- I hereby certify that I have prepared th' pplication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules.and .re' ul ns of the San Joaquin Local Health District. (Owner and/or Contractor) x Title --------------- By:------== •---�- - ------ -----------------------------------•-------9.. (Title) (Plot plan, showing size of lot, location o syste in relation to wells, buildin s, etc., can be laced on reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- ------ --- ---------------- DATE------------ - ----------------- REVIEWED BY--------------------------- -------- DATE---------- BUILDING PERMIT ISSUED-------------------------------- ----------•------------------•--------------- DATE Alterations and/or recom ndations:-- -------------- ------------------ ----- -------- f 41 ------ •---- ---- �� -•• -. ------------ - ------c ` ------- �' ------- -• -------�- - ----- ------------- -- --------------------------- ------ ----- --------------------------- FINAL INSPECTION BY:..... ----- Date. f $AN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB-9 REVfSE� 13-59 F.P.CO.2M"o t -