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APPLICATION FOR SANITATION PERMIT Permit No. 117..7�..a ' (Complete in Duplicate) This Permit Expires 1 Year From Date Issued 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 application is made in compliant with o my Ordinance No. 549. JOB ADDRESS w A LOCATIO ii __ � ---------- Owner's Name-------- - t- ------------------•- -------------------------- -- - --------------------------------- -- Phone------------------------------------ Address-------_-------------------- ---•-------------------------------Address---------•------------------ ---------•--------------------------------•----•-•----------------------------•-•----------------------------------------•----------•-------•---------------- Contractor's Name------- ----------_-------------------------- --cc..--------------------!- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ fa`ili��`C.ourt ❑ Motel ❑ Other ❑ m ^� Number of living units:>___j___ Number of bedrooms --4-- Number of baths __. Lot size L.-axAgQ-----T•--- - f r Water Supply: Public system ❑ Community system ❑ Private A Dep �4Water Table _!�_- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam VL Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No I&/ New Construction: Yes ❑ No N- FHA/VA: Yes ❑ No TYPEi OF INSTALLATION AND SPECIFICATIONS: ' 4 (No septic tank or cesspool permitted if vp sewer is available within 200 feeft.)Sept Tank: Distance from nearest well------------- -_Distance from foundation_-_._.j-0____.--Material_ .Pik--------------__--- No. of compartments------7-----------------Size---- Liquid depth_----4--_---.---------Capacity.....I 07P7��---- Disposal Field: Distance from nearest well.-- -------Distance from foundation__� !�.......Distance to nearest lot lline-----4----. E Number of lines---------- ----- ------ ---- Length of each line---�--9CQ_-- 1+--------.W'sdth of trench--`-�---.�,---.---------------_---•- Type of filter materi r�_ .___Depth of filter material_____(_____-___...Total length___-� I'?_------------------------ ___ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- 4 ❑ Number of pits----------------------Lining material---------- ------------Size: Diameter-----------------------Depth------------_-------------------- I Cesspool: Distance' from nearest well-----------------Distance'from foundation------------------- Lining material-------------------.----------------- If% ❑ Sizer'Diameter---------------------- ---------- s ----Depth---- --------------------------- --------Liquid Capacity -----------------------ga s. Priv r' Distance from nearest well __________________________________--------------Distance from nearest building---------------------_________.__-.______- ❑ f , , Distance to nearest lot line------------------ -------------------------- -------------------------------------------- -------------•--------------- --------------- Remodelingand/or repairing;(describe):--- ........ -----------------------------...-----------------------------------------------•--------------•------------------------------------•---- -----------••----•------ -------------•-------------------------- 4. 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. 6 ----------- -----------------------------------------------------------------_-•------------ -----(Owner and/or Contract' �- -- By:--------------•-------------•--•---------------- -------- -------------------------- ---------------------------------------------(Title)---------------------;------ ---------.------- t (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 h APPLICATION ACCEPTED BY-------------------------- --- ----- ---- - ----- -------------------------------------------- DATE T REVIEWEDBY------------------------------------- ------- - -- -- - - --------------------------- DATE = BUILDINGPERMIT ISSUED-------------------------=----- ----- ----------------------------------------------------- ------ DATE----- --------•------------------------------`------------- Alterationsand/or recommendations--------------- ------=-------------------------- --•-------- ----------------------------- -----•------- ---------------------------------------------- . . --- . -- -- ---- --- ---- ----- -- --- 9w p __ __ -- - --- -_ _ �:. :____ - __ _ = -r te ------------------------ .0v __.. "'T) !C-;FCO� Tf F7 F, r " INSPECTION BY:.-- - Date-_:--------- --------- JO UI CAL H ALTH DISTRICT % 130 South American Street 300 West Oak Street 1312 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy. California 1 ES-9-2M Revised k