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APPLICATION FOR SANITATION PERMIT Permit No. ___,(-_/_ .-. (Complete in Duplicate) ��T � Date Issued .-'�'L_G�.�t.._-- ate.. !/ /� r Application is hereby made to the San Joaquin Local Health District for a permit to constru t and,jnstall the work herein described. This application is made in compliance v&b County Ordinance No. 549. # s L JOBADDRESSXAD LOC TION--- r --------- - ----------- -- -------------------------------------------------------------------- f,, �Owner's Name4� 1 f tl f � �'`�11 f "'----------------=-------------------------------------- ----------- Phone._ -3S--- -FAddAddress-------------------------------- ress-------------------------------- .......... ----------------------------------------------------=------------------- Contractor's Name -------------- ------------------------------------------- --------------- Phone--------------------------- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court E] Motel F] Other ❑ i Number of living units: - ___✓_ Number of bedrooms ____Q Number of baths _1___ Lot size .t C__�_,x------ _______-__ F Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table W ft. Character of soil to a depth of 3 feet: Sand 0( Gravel E❑ Sandy Loam ❑' Clay Loam [] Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes El No" New Construction: Ye No ❑ FHA/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_4 I�_____Distance from foundation___ _ Material___ _ __ No. of compartments-----_ -----------------Size _Liquid depth____ -------------Capacity.- r� , Disposal Field: Distance from nearest well._4k)-`-._Distance from foundation___dRP----------Distance to nearest lot line Number of lines-__----- Length of each line_____ ?__L�_f_________.Width of Type of filter mate ria l_4074s___ Depth of filter material-/ -------------- length___._1.0--d__________-_•____-____ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__________.____._ ❑ Number of pifs----------------------Lining material----------------------.Size: Diameter------------------____Depth--------- --------__------------ Cesspool: Distance from nearest well----------_------Distance from foundation--------------._.__.Lining material_-------_----------_---_-____________- ❑ Size: Diameter...:...--=•--------------------------Depth----------------------------------------------------Liquid Capacity.------------------------gals-.7m Privy: Distance from nearest well------------------------------------------------- from nearest building------------------------------------------- I ❑ Distance to nearest lot line----------------------------------------------------------------------- --------------------------------------------------------------------- Reodelin d re airin dw �Im g an_/or P { escri ---•------ �Y� i •G�-fid- = 4ra -E..a----------- /?---r---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. law nd rules and regulat' ns of the San Joaquin Local Health District. (Signed) ---.. ..._ -•-- -- -- �"-'-- - - - -- ------------ ------------------------------------------------------------------------------{Owner and/or Contractor] By:----'-----------•--•------•------------------------------------------------------------------------------------------------------(Title)-------------------------------------------- ------------------ (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 ----------------- REVIEWEDBY----------------------------------------------- --------- -- ....... -- ---- -- - ------- DATE-- -- - BUILDING PERMIT ISSUED---------------- x------ ---- -------- --- ----------- DATE------------------------------------------------------------- Alterations and/or recommendations: ---------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------•------ -------------------------------------- FINAL INSPECTION BY:.____-- -- - Date---- ------- ------------ -- 3 --- 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---9-2.M , Revised 1.57 F.P.CO.