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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) X ( Date Issued _' d Application is hereby made to the San Joaquin Local Health District for permit to construct and install the wort: herein described. This application is made in compliance with County Ordinance No. 549. - " JOB ADDRESS AND LOCATION;._`-K'_-----4------ �Q ------------- -- ------------------- Owner's x----------------------- Address -------------------------------------------------------------------------=----------- ----•------- ------------------------- -•--------------------------=----------- ! ----------------------- Contractor's Name-------C's�'__��----'------------------ -------'--- --------- ------------------------------------------ Phone----------------------------------- { Installation will serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ }' ' t _X -- e1 Number of living units: ---i--- Number of bedrooms __ __ Numlaer of 7..Vbaths .��_ Lot size --�1 _____ ._3_LS__�____ Wafer Supply: Public system ElCommuri'ity System ❑ -Private ❑ -'Depth to Water Table -------- ft.--� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy-Loam.❑ ,Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made. Yes [] No ❑ New Construction: Yes ❑0-N8 ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: E (No sepfic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank': Distance from nearest well______________ Distance from foundation-_______-___'.___..Material______.. ._.-_________________________________`�^� 4.' 'Tti vl� No. of compartments------------------------ S;ze---------------------------- ---Liquid depth------------ ------------'-Capacity-----=---------------- Disposal Field: Distance from nearest well.. _Q°..f Distance from found ation`-- -------Distance to nearest lot line------ _i------ SLX(5�tr ^% Number of lines---------i-------------------------Length of each line------- ---------.Width of trench-----:7?�-_4* ---____..___-_--. t Type of filter material__.t'_.0_te:L_-___Depth of-filter materialy_ _!`_._.__._Total length-------3_Q_Q;___-------------___ rte' t � . .� � ,.�_ _ t, � t . :F Seepage Pit: Distance to nearest well__= !-_(2 ?___ Distance from foundation_ { � _..Distance to nearest lot .____- Number of pits------- material__ ` ° i p g __Size: Diameter°G.---Ifo----_.Depth---- 6. -------------... Cesspool: Distance from nearest well:___'_____y-._: Distance from foundatio L r > , .. � � ' f n_'.%__.:.: 1.____.Lining material_._:_____ --- ❑ Size: Diameter ; Depth ---------------- --- - ---- - Liquid Capacity..--------------------------gals. Privy: Distance from nearest well-___-._--------------------------------------__Distance4rom nearest building___________________________.__----___-- ❑ Distance to nearest-lot.line-_.___:__:_--_-__�_____r~�-^_ Remodeling and/or repairing (describe)=---------------------- = --------------•----------------------•-------------------------•----------------------------- -------------------------•------------------------------------- + . Ih ork w I hereby certify that-I have prepared this application and that the will-be done in accordance with San Joaquin County ordinances, Stafe laws, and rules and regulations of the San Joaquin Local Health District. �V d (Signe ) € _. - (Owner and/or Contractor) By:. - `--------------------- ---------------------------------------------------== --(Title}------------------ ---F---------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells; buildings, etc.�can be placed an reverse side). FOR DEPARTMENT USE ONLY 6 s APPLICATION ACCEPTED BY------C--= REVIEWED BY --------------------=------------------E-- --------------: DATE ------------------------- BUILDINGPERMIT ISSUED------------------------------------- ----------------------=-•------------- ------------------------- DATE.-------------------- Alterations and/or recommendations:-_j'---r0--- ----------<AAd ,"-•-- � --------!0-,K.............. ---------------- . i -----------------------•--------=-----:------------------------------- ----------------------------------------------------------------------------------------------------•--------------------------------•-------------- --------------------•--•-----------------------•---- --------------- --------•--------------- 1 FINAL INSPECTION BY:__C_ 03� _�2 -�`- -_---- Date.-(Lz = �'ti ---------------- i r SAN JOAQUIN LOCAL HEALTH DISTRICT °130 South American Street 300 West Oak Street f c132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California " Mnteca, California Tracy, California ES-9-2M , Revised 1.57 F.P.CQ.