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— — Iv ft�- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --�-�-]�-- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicatiori is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION.r3kfet,� ,c. ',•�i � - ------------------------ Owners Name/�_---/- ----- �1 --- - Phone - -- -------------- ------------- ------------------------------------ ---- ----------------- Contractor's Named--------------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: _ _____ Number of bedrooms .j___._ Number of baths 4k-_ Lot size -- ------------------------------------ --------------- Water Supply: Public system ❑ Community system ❑ Private E] Depth to Water Table!, ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam M Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ] 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 .0--_-----_Distance from founclation/A________.._..Material__ No. of compartments----�---- -------------Size-------------------------------Liquid depth----_--------- Capacity 1CfT Disposal Field: Distance from nearest weil_.6'P___----.Distance from foundationAq------------Distance to nearest lot line___________ An Number of lines___.__�_____ _ __..__ ngth of each line----gP_---_ __ Width of Type of filter material_ -. epth of filter material___/Z-- ____Total length___. --___________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation----------__.-------Distance to nearest lot line-------__________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-________--_----_________.__-----__. ❑ Size: Diameter--------------------------------------Depth-------------------------- -------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest.buiiding---------------------------____----------. ❑ Distance to nearest lot line---------------------------------- -------------------------------------------------------------------- -------------------------------------- Remodeling and/or repairing (describe):---------------------------------------------------------------------------•-------------------�:---------------------------- ---------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. (Signed).�- ---- --- ---- [ 1 E - -----------------------------------------------------------------------------(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 $Y- -------------------------------------------------------------------- DATE_ `e REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------ DATE BUILDING PERMIT ISSUED------------ ------------------------------------------------------------------------------------ --- DATE Alterations and/or recommendations----------------------------------------------------------------------------------------------------------- ... ------------------------------------------------------------------------------------------------------------------------------------------------------------------•----- ------------------------------------ ---------------- --------------------------- � ��' � FINAL INSPECTION BY Date--- - - - - - ------------------- ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California I ES-9-2M , Revised 1.57 F-P.CO. {