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y APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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 County �OJrdinan e19� JOB ADDRESS AND LOCATION--A---------- ------------------•-------�------�----Q----------------------------------------------------------------- ----- Owner's Name---GD �`''' '` '�--------�-1 - -• -- - �sv_._�-fl..�'Lf�I- Phone ------- ------------ Address------------ a `'----------------------------------------------------------------------------------------------------------------------------------- Contractor`s Name--•---Xke-�------"--e- /rI------- ,/ate -----�1 .� C `� ------ Phone---,v- Installation hone--- Installation will serve: Residence E] A artment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ o Number of living units: _� __ Number of bedrooms _J7-- Number of baths _l7__ Lot size _.1-G_-C--fL1_---_-------[S`�'�cS�---_ Water Supply: Public system [4 Community system ❑ Private ❑ Depth to Water Table IPP-_ ft. Character of soil to a depth of 3 feet: Sand p Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 4 Hardpan ❑ f Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (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. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well_________________Distance from foundation.___---•._-----_--_.Distance to nearest lot line----------------- Number of lines-------------------------- --------Length of eac ne___-- (---- ----.Width of tr 2 S!A ----------------- Type of filter mats ion--] '--'tee YP �-----Depth of filter mat Total length --- - -------- Seepage Pit: Distance to nearestwell_--_ --------------Distance from foundation_a"P-----------Distance to nearest lot line--'-/------- [ Number of pits-------- ------------Lining m � ---- ¢e: iameter_.j_G_-------------Depth_-- -- Cesspool: Distance from nearest weld-----------------Distance from foundation----------------.---Lining material-------------------------------------- Size: Diameter---------------------------- --- ----De th-------------------------- -------- ----------------Li Liquid Capacity gals. \ I ❑ p q p Y - - - - --- -g Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/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 +he San Joaquin Local Health District. 6"t4 (Signed)--------------------------------------------------------------- ------ ---- ------ - ---------- ------.. ----4----------------(Owner and/or Contractor) BY-------------------------------------------------------------------------------------- ------ --------------------------------------(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 t� APPLICATION ACCEPTED BY--- ----- ---------------------------•------------------------------ DATE--------- 1 �f REVIEWEDBY------------------------------------------------------------------------------------------------------------------- --------• DATE BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------ --------------------- -------------------------------- Alterations and/or recommendations--------- ------------- ----------------- -- ----------------------------------- ------------ -•----------- ------------------------•- ---------------------------------�?n -1� - QN.-Crt c---- ----------------------------------- ------------------------------------------------------------------�`------ -��-----I AF--- r__R- O7-��--------CZ ttlf�l r -- ------------ ------ ---- - , --------------------------------- - FINALINS ----- - -------- ----- -- --------- Date--- -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 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.