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a 1�� T APPLICATION FOR SANITATION PERMIT Permit No. L; (Complete in Duplicate) Date Issued --- p 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. a JOB ADDRESS AND LOCATION----- f----------- - ........ Phone----.- ------------------ Owner's Name.- �i"- - Address------------_ f ------------------------- ------ ---------------------------------------------------- --- ---._. Phone------------------------ ' --- ----- �f�"�•� -- -- ---- - --:------- Contractor s Name____:__---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ O-10 ther ❑ Number of living units: _ --- Number of bedrooms __4Z_ Number of baths ----�_ Lot size _��-�- -.- - Water Supply: Public system RIICommunity system El Private E] Depth to Water Table ft� I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: Yes ❑ No A# - New Construction: Yes ❑ No.�HA/VA: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic rank or'cesspool permitted if public sewer is available within 200 feet.) epti Tank: Distance from nearest well-----------------Distance from foundation____________________Material--.--_..__-_--___..____----_______---___-..___. " No. of compartments--------------------------Size------------------------ ------Liquid depth--------------------------Capacity------------ ------ Disp al"field: Distance from 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------------------:__----Total length--------------------------------------- Seepage Pit: Distance to siearest wel{-----�_-------Distance from ou anon___ 6+ r , _...___.Distance to nearest lot lines___ ` i " Number of pits----- -----------_Lining material/ ____- _.Size: Diameter_._ Deptn___ � Cesspool: Distance from nearest well__________------Distance from foundation___--_-___---------Lining material___---_---.___.--________--__-_____- ❑ Size: Diameter--------------------- ---------Depth-----------------------------------------------------Liquid Capacity----------------------------gals. 1( Distance from nearest building Privy: Distance from rom nearest well � 9------------------------------------------ ❑ R Distance to nearest lot line------------------------- -------------------------- ---------------------•------------------------------------------------ Remodeling and repairing (describe): ------------------ -------------------------.---- - iv ! --------------------------•----- ---------------------------•------------- \ --------- ------------------------------ ---••---------•--------------- -------------•--------------------------------_..-..----•----------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepardd this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and reg tions of the San Joaquin Local Health District. 1 - ----------------- - Contractor)ractor) (Signed)-------- --- - ..r- ~`--------(Title)----------a-f-f-I- s ----------- •-- (Plot plan, showing size of ! ocation 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 ✓t BUILDING PERMIT ISSUED DATE----- ------------- ------------------------------- Alterations and/or recommendations-- -- ---= --- ---'------------------------------------------------------------------------------- ---------------------------------------- - d ------•--------------------------------------------------------- ------------------------------- - -- - - ------------------------------------------------------ ---------------- - ---•-- --- -------------- ------------------------ ----------------------:-------- ------------------- ------------------- r t } ` FINAL INSPECTION ------ Date---- -------.--------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak S+rae+ ` + 1324Sycamore Street , 814 North "C" Street S+ock+on, California Lodi, California Manteca, California Tracy, California i FS-9-21x1 , Rev'ssed 1-57 F.P.CO.