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3p APPLICATION FG._.:- SANITATION PERMIT Permit No. ___ .1_.. .. (Complete in Duplicate) F 2- l_' Date Issued __._ � _ . Application is hereby made to the San;Joaquin'Local Health District for a permit to consOuct'end'install the work herein described. This application is made in compliance with County Ordinance No. 549.' ! _ -------- , ,. ----- .- k- ---*JOB%ADDRESS AND LOCATION------ �� --- Owner's Name.__ .. - --- - ---- - -------- ----------------- ......... -- yis fi , Address---------------- ---_----=------=--------------------------------------•---- --------=-------------_-- -----------------._--------------- ---- Contractor's Name--.---____-- "--. "_-- _ = ----= - ---------- ------------------------------ Installation will serve: Residence Apart e t-House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1___" Number of bedrooms Number of baths __f___'Lot size __"_".."-_":""""___________________________________________ Water Supply: Public system ❑a CoT" mur6ty system Pn.v_ate. . Depth to Wafer Table'3ft; Character of soil to a depth of 3 feet:.. Sand [I Gravel E] Sandy. Loam ❑ Clay Loam ❑ Clay ❑ Adoben, Hardpan ❑ Previous Application Made: Yes k ❑No � � m ❑j— pp �"`rr,New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFIC'TIONS: # (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance,from nearest well___ :__`Distance from foundation________________ Material No, Dis tlField: D stance from nearest well `�"�""___ _.D'stance from -{o"---"-"-"Liquid depth-_________________"___"-_Capacity__________-"_"____.._._ppundafion_._3"O----------Distance to nearest lot line_____-. Number J _ a . ngfh of each line-----3b----------=------Width of french _-2lt------------_----------- ----------- Type of filer mateal _� ��. _ D of filter rimaterial___._2B-----------Total length ...... Seepage Pit: Distance to nearest well_,____ ___ _____ Distance from" foundation------------- fo nearest lot line____.____._____. ❑ Number of pits----------------------Lining maferial---------------_-'------Size: Diameter---_------•------------.Depfh_____------_--•---------------_-• Cesspool- Distance from nearest well ._-Distance from foundation____________ ______Lining materia----------------- __.____-__.___.___ G El Size: Diameter---------------- -- Depth-------------------------- -- --------------- Liquid Capacity-----------------------------gal Privy: ; Distance from nearest well __ -------------------------------- Distance from nearest building ❑ Distance to nearest lot line- "_ = = = ---------------------- 1 y Remodeling and/or repairing (describe): 1 ( CQ.( cy___tM d>? __ C�s_ __ � ......... ...... --------- ----------------------------------------------------------------------- --•----- -=.. i = ------------- ----------------------.------------------------------__"__"____"____"__.____"_-•_--__-.-.__Y_________-..-._______---_________.___-____._____._.-.__________-________.__---_•.__________-_._________ I hereby certify that I,have prepared this application and that the work will be done --------------------------------------------------------------------- E a oidan`ce with Sen Joaq County ordinances, State laws, and rules and regulations of A San Joa u1n Local�Health District. (Signf _ ____ r ed)--------- ------------------.(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). 1 FOR DEPARTMENT USE ONLY ti } APPLICATION ACCEPTED BY-- -- ---- ----------------------------------------------------- DATE! - ----- -------- 7 REVIEWED BY ----- DATE- ------ BUILDING PERMIT ISSUED------------------------------------------------'--------------------------------------------=---------DATE-------------------- Alterationsand/or recommendations:---T__-_:----------------------------------------- ------------------------------------------------------------------------------•------------------------ ------------------- - E ' --- -------••-----------•------------------------------------------•-•- --- ----------------=--"-------------•---- --------- -"--•---- =--•----------------------- -----------------•----------- v ------------------------------------------- �: --- FINAL INSPECTION BY: = - --------------------------- . - _ ` - = Date-'- SAN JOAQUIN LOCAL HEALTH DIST CT 130 South American Street 300 West Oak Street 132 Sycamore Stree+ 814 North "C" Street Stockton, California w. Lodi, California Manteca, California Tracy, California ES-7-21x1 , Revised 1.57 F.P.CO.