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APPLICATION FOR SANITATION PERMIT Permit No. ._��-��_.. (Complete in Duplicate) Date Issued F 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 County Ord' ante No. 549. JOBADDRESS LOCn.ATION------/ -�--- ------- ---------------------------------------------------------------------------------------------.------------------------- Owner's Name-- - --------•-- ------- ----- ------ ---------- •---------------- ----- Phone------------------------------------ Address i ------ Contractor's Name---------------- --- --------- ----•----- -•---------------------------------------------------_=---------------------------------------- Phone----------------------------------- Installation will serve: Residence��partment House E] Commercial E] Trailer Court ❑ Motel ❑ Other ❑ 1 / Number of living units: _;4mmunify mber of bedrooms _�t___ Number of baths _-�____ Lot size _ _- -�Q_+ ---------------_----------___ pp y� Y Y ❑ ❑ p Water Su I Publics stem 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 Applicafion Made: Yes ❑ No New Construction: Yes [�No ❑ FHA/VA: Yes ❑ No Q_ s TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank!or:cesspool permitted,if-public-sewer is available within 200 feef Septic ank: Distance from nearest well��Distance from foundation�_�_a �__.Material_ ------------------------- ° _Ca acs No. of compartments- 9;---- --- Size --------------------- - --- ---'- - --__Liquid,depth ---------------------•-- P tY=----- --90- Dispas Field: Distance from nearesti ' Distance from foundation� ________ _:.Distance to nearest lot line_-_� ----- , Number of lines_________ : - Length of each line__?_ _, _ _j_.Width of trench.____._____� _Tte r ma ---- -._._ Distance om found,ation--------------------Disal length-------_----------0----------$eepa a Pit: Dataoaf Coenarestrw �J epth of filter material____.- O ttanc to nearest lot line___ - � j/ 's gi Number of pits_____.__!___..______Lining, maferial___+ i�--C-...Size`s Diameter-.- ---- ---_ea�__..___Depth___._.._ u_ �_____________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____________________________________ ❑ Size: Diameter--------------------------------------Depth------- -----------------------------------------.-Liquid Capacity----------------------------gals. Priv Distance from nearest well_____________________ -__Distance from nearest building _______. ❑Y -------------------- ------------------- ----------------------- --- Distance to nearest lot line---------------------------------------------------------------- _ { , I Remode'ng nd/or repairin , (d s ribe)=------------------------------------- --------------------------------------------------------- -------------------------------------- -- ` � -- - ---- --------- -- '----------------------------------------------------------------------------------------------------------------------------------------------------------------- i -------------------------------------------------------••-•-------•-----------•-------------------------------•--------------------------------------------•----------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, laws, and rules and reg tions of the San Joaquin Local Health District. I (Signed) --------------,---- -------------- -- -------------------------=-------------------------------- ___(Owner and/or Contractor) 1 By:----------------------------------------------------------------------------------------------------------------------I------------(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 BY "------------------------------------------- DATE 1 --------------- REVIEWEDBY---------------------------- --- --------- ------------------------------------------------------- ------------ DATE-- !W,. ------------=------------------------------------- BUILDING PERMIT ISSUED-------------------------------------------- DATE ------------------- ------------------------------ -------------------- Alterations and/or recommendations:------------------------- -' Ir--------------------- ----------------------------------------------------------------------- --------------------------------------?2.7---------DE.f>_a._r-1_---------f `J --------------- �-- ---------------------•------------------- ---------------------------�P T��-----.zi�Nn------- o.yam �-r AK-A---------.=�-`----------F!_A-�----------°:� ----- -- , , ----------------------------------------------------------- -------------- ------------------------------------------------------------------------------------------------- ------------------------------------ -----/ ---- ' ' - - P FINAL INSPECTION By. - Date J rr SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, Californie Manteca, California Tracy, California -ES-9-2M , Revisea }.57 F.P.CO.