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x APPLICATION FOR SANITATION PERMIT Permit No. ...1-_ .....`...�. (Complete in Duplicate) p (Z V Date Issued This Permit Expires 1 Year From 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 compliance with Countyy Ordina ce No. 549. JOB ADDRESS AND LOCA 1 N. f 77 ` .C!_- -------------------- ------ ----- ------------------------------------------------ Owner's Name_ .-•------ - ----••--•-------------------- ------ Phone Address--------1.�.. _, ..-�.0 - - - --- ......--•-- - ._- Contractor's Name---------------------------------------------------------------------------------------------- --- ----------------------------------------.-- Phone...-----------------_----------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: )------ Number of bedrooms J---- Number of baths/----- Lot size sre+ 40------------------------------------ Water Supply: Public system ❑ Community system ❑ Private K }Depth to Water Tablet-0_- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam N Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No fI New Construction: Yes 0 No N FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - - -- - - (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) Se ' Tank: Distance from nearest well-----------------Distance from foundation-..___--_-_-----.-.Material------.--------..-.------_-_-_-___._____.----. ❑ No. of compartments---------- -------------Size---------------•---------------Liquid depth--------------------------Capacity-----------•----------- i osal Field: Distance from nearest-well-------- --------Distance from foundation------------------.-Distance to nearest lot line-------.---.---_. Number of lines-----------------------------------Length of each line--------`--------------------Width of french------------------------------------ Type of filter material-------------------------Depth of filter material------------------.---- otal length-----------------_--.----------.----_----- Seepage Pit: Distance to nearest well..-- -Q_-_ Distance 'from foundation----' -_�_...._-_.Distanceto nearest lot line---5-----.----_ Number of pits.------�._-�---------Lining material _�4A_Size: Diameter.- -?C- -..--.Depth--.-.�.._-._---------------- Cesspool: Distance from nearesf,well-----------------Distance rom foundation--.-_______-.-----..Lining material-----.----------__._-----__-_------. ❑ Size: Diameter--------------------------------------Depth------------------------------ ---------------------Liquid Capacity-...---------------- -------gals. Privy: Distance from nearesf:well-------------------------------__-----.-.------Distance from nearest building-----------------------------..--...____- [] Distance to nearest lot line----------------------------------- ------------------------------------ --------------------------------------------------------- --------- Remodeling anti/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`} p�'°" ± ""r,005a (Owner and/or Contractor) .� -------------------- ----------- ----------------------------------------------------------- {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 APPLICATIONACCEPTED BY- - - -- -- ----- ----•-------- ------------------------------------------------------------ DATE----7-F.-1..!1�-------------------------------- REVIEWEDBY--------------------------------------------- -------------------- ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations--------------- - -----------------------------------------------=-----•------------------•--------------------- --•------------------------------ ------------ ------------------------ --------•----------------------•------------------------ ------------------------------------------------------------------------------------------------------------------------ -------------------•----------------•-------------------------•-------------------- --------------------------------------------------------------------------...---------•------------------------------------------------ ---------------- ------------------------------------------------------------ ----------------------------------------------------•-------------- ---------------------------------------------------------------------------- --------------------- --------------------- __loge -------•----•------- l ' � -3'�t� FINAL INSPECTION BY: -- - - Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamora Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-92M Revised 8 'S9 F.P.C..