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J APPLICATION FOR SANITATION PERMIT Permit No. --�L-/ (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 Ordinance No. 549. ss l/ JOB ADDRESS AN LOCATION. _�__.�t�. -------------li' ; y.-------- - ------ ------ Owner's �fz Phone f ) � AddressJ --------------------------------------------- ----------------- Contractor's Name----------------- ---- C -- -• ---•--� ---------------------------------------------------------------------------------------- Phone----------------------------------. Installation will serve: Residence ®Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other F1 Number of living units: _ --- Number of bedrooms _-��-Number of baths -------- Lot size _--- _ -------------------------- Water Supply: Public system 0 Community system E] Private E] Depth-to Water Table ft. Character of soil to a depth of 3 feet:, Sand ❑ Gravel ❑ Sandy Loam ❑ Cia ;Loam ❑ 11 Clay ❑ Ado e,,2 Hardpan ❑ } Previous Application Made: Yes ❑ No W New Construction: Yes ❑ No FNA/VA: Yes ❑ Na TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if pgujblic sewer is available within 200 feet.) �. Septic 'ank: Distance from nearest well_!!f_c')-AX—Distange�f'omrfour)dation__--_/�__----.Mate 'al----- ® No. of compartments------t�._ ----- ----- ------1Liquid depth-------- ----------------Capaci --____-- ty-- Disposal Field: A Distance from nearest well________----------Distance tram foundation_----_-____--___-_-Distance to nearest lot line------------------ ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench Type of filter material-------------------------Depth of filter material------------------------Total length--__---------_-_-_--------------_- Seepage Pit: Distance to nearest well------------------_-_Distance from foundation--------------------Distance to nearest lot line-----_-_._------_ F. ❑ Number ofits--------------- p --Lining material-----------------------Size: Diameter------------------ -Depth-------- ---------------- Cesspool: Distance-from nearest well-----------------Distance from;foundation--------------------Lining material---_-------------__------__.-----__ ❑ Size: Diameter------------------------ - -----------Depth------ --------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------------------------------.,.-Distancejrom nearest building-------------------------------a ❑' . . Distance to nearest lot line_ Remodeling and/or repairing (describe):_ ------------------- " •'d,`� �` - -----r -------- `-'--y- -- --••------------------------•------ - - - - - -- ----------- - -- -- . _--- "- -------------------------------- ---- - ----- ------ -------- -- -----------------------------•-----------------------••---•---------------------------------- ------------------------------------------------------------------------ 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. (Signed) `_:/ _ =' � �C, � _ �0 n� r/ ; . — ------------------------------------------- Ow, r and/or Contractor) By:----------------------------------- ---------------------------------------------------------------------(Title)------------- ------------------------------- i (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----- // _) ---------------- REVIEWED BY---------------------------------- - ---------------------------------------------------------- DATE----- 7 UILDIN PERMIT ISSUED------_--------------- ------------------------------------------------------ ------------------- DATE------------------- Alterations and/or recommendations:------------------------------------ ----------------------------------------------------------------------------------------- ----------------- ---- I ------------------------------------ -----------------------------------------------------------------------------------------_-------------------------------------------------------------------------------------------- ------------------------------------- •------------------------------- ----------------------------------- ---- - ----------------------------- FINAL INSPECTION BY:-- _---r:- P2:741_4 _ --------- -- Date-----------��%% SAN JOAQUIN LOCAL HEALTH DISTRIC4' 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1.57 F-P.CO.