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-✓�S� _ APPLICATION FOR � i+ No, SANITATION PERMIT Perin (Complete in Duplicate) Date Issued Application is hereby made to the Son Joaquin Local Health District for a-permit to c struct and install the w 1 This application is made in compliance with County O�di nce Na. 549. a ork herein described. 1 JOB ADDRESS A L AT � C (p r r --------- --•------------- -- - iName------ -------=- - `- ------------------------ Owner's --- ---------- ------- Phone---- - ----- ------ - _ �_...r. A dress----------------•- -----------------------------------Contractor's ------ -- ---------- --•---•-- - Name__.5,.---- -- � ,,, --------------------•-------, --------•------ ------•------------•-- Installation will serve: Residence Apart,"ent`l-{ouse Phone------ ❑ Commercial ❑ Trailer Court ❑f MafeI Other [] ! Number of living units: __j___ mbar of bedrooms l f ___ Number of baths __1--- Lot size ____ �-�C �i Water Supply: Public system Commn'it system ------_-•-' PP y: l Y Y ❑ Private ❑ Depth to Water Table _::.-_.:: ft: _ Character of soil to a`�depth of 3 fee#: Sand Gravel ❑ Sandy Loam Cfay Loam ❑ --- Previous Application Made: Yes Y ❑ Adobe❑ Hardpan ❑ ❑ No New Construction: _s J No ❑ FHA%VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: y a (No septic tank or'cesspool permitted 'f ublic sewer is available within 200 feet. f + ) Septic nk: Distance from nearest welf_�{I- istance from fou cation ____�.� rf 01, No.'of compartments------ � - t . ----Materia `---------------------• ------------ - ize__. Llquidfde th -�-+.` Ca acit ! Dispos Field: Distance from nearest well-..- # ! P Y- QQ __ Distance from foundation___ '- -_- ,.Number of lines - -- --.---Distance to nearest lot line___�"""_""". - ---- --___ Length of each line" �- / t Type of filter materif�� ldt€� of trench,________- �,�- --- - -- _�>'��'Depth of filter material-- _r7 - "'" -Total length-----------� � -f______.__-. Seepage Pit: bisfance to nearest well_':_-'_t!7 '""_Distance from foundation"_-�_1-"" ----[ Distance to nearest lot line_________________ ❑ Number of pits---------------- ----Lining material-------- " -- .-__-- Size: Diameter-------------'----------Depth---------------------- Cesspool: Distance from nearest well-----------------Distance from foundation______-"-__-ill .Lining material__.-______-"""--".-_-"-_-""_-"-•""-_- ❑ Size: Diameter------------------------ ---' t Depth = = Liquid Capacity- ---------------------------gals. Privy: Distance from nearest well__:-"-__"--__:-�_"-__- --------------------------Distance from .nearest building_:-___--_____.------------------------ Distance ❑ to nearest lot line- "-_- "-_ r - -- Remodeling and/or repairing (describe):---:------------- --"-" -------•-- ------------------------ I -------------------•----------------•-----------"--------"---------- -----------•--------•---------•---- -----••--•-----•--------------------------- 1-hereby ------;------------=----•-------------------------------•---•---------------------------- ----- l ---------------- certify t,a n have prepared this application and that +he work will be done in accordance with San Joaquin County ry ordinances, Sta a laws, and rules and re ulations of the San Joaquin Local Health District. ` (Signed) �Aj1 4 _----- _---------- _----------------------------------------------------------------- By:---------------------•----•-----=-----•--•---•----- (Owner and/or Contractor) --------•----------•------------- ----------(Title) . Plat plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY_ $ -- ----------= ------ DATE_g REVIEWED BY -- l~ . --- ----------------------------------------------------------------------------- DATE_ - BUILDING PERMIT ISSUED r — DATE ------------------•------------------------------ Alterations and/or re- mmendationsa_ -___i.___._--.____.._____`-•fl - ------------ f��-157---�-�'�------ � --- ------•-------•-�-----• . ------- _ - . s = .r t"� ---------------- _ - ��. , - 5" ---- ------ , ------fir --------------------------------------------------------------- FINAL INSPECTION BY:_:_— ----- ----------------------------------- HEALTH ------------------------ - HEALTH DISTRICT 130 South American Street 300 Wes} Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F,P.CO.