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q a l APPLICATION FOR SANITATION PERMIT 'Permit No. (Complete in Duplicate) ' Date Issued ______ .__l�_Sy 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. JOB ADDRESS AND LOCATI eN-----------el = L- �)--:-~�--------��-'~----�,..-:_.__-._=-�"f-------------------- Owner's Name IkePhone (� = -- - �---- -- '3 Address---............... ,_� 7- 9n ------------ �' �-E_ I F r•----�-,,-/------------- •-----..... Contractor's Name_________- - - Phone,C �_ ' _-------------- Installation ---f_6-__ ------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths -------- Lot size ---______________________________________________________ Water Supply: Public system E] Community system ❑ Private [-] Depth to Waterable -------- ft. Character of soil to a depth of 3 feet:. Sand ❑ Gravel ❑ Sandy loam ❑ Clay Loam ❑ Clay E] Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ PHA%VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: W (No septic tank or'cesspool per miffed if public sewer is available within 200 feet.) 1 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----------------- -1d ❑ Number of lines--------------------------- -- -:_-Leng#h of each line------------------------------Width of trench----------------------------_-:., � } � Type of fitter material-----------------------"Depth'of filter material-----------------------Total length------------------------ ---------------- - Seepage Pit: Distance to nearest well_____________________Distance from foundation--------------_____.Distance to nearest lof line----------- I ❑ Number of pits------- --------------Lining material--- ---------- -- Size: Diameter-----------------------Depth--------------------------------- a v' Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- p F '❑ �Size: Diameter. 4 Depth -------------- -----------------i----Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building-----___-______________________________ �` r ❑ ^Distance to nearest tot line--- - ------------------------------------------- - Remodeling and/or repairing (describe):_________ - � � +�� - '- _° . — - Yr ------------------------------------------ -------------------------------------------------------------------- ----------------------------- ---------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this``application arid"that the work will 6e done"in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. � I - ---------- --------------------------------------- -- -----------------------(Owner and/or Contractor) -! By:_-------------------------------------------------------- ---)�------ - - - VP ----------------------------------------------•----------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of sysfefn in relation to wells, buildings, etc., can be placed on reverse side). ' ; ! _IFOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- + `"`----------------- ------------------•---------------------------- DATE----6_ (d 0 REVIEWED BY---------------------- I DATE BUILDING PERMIT ISSUED--------------------------------------9 ------------------------------------------------------------------- DATE---------- Alterations and/or recommendations:-------------- ---=--------------------- ---------------------------------------------------------------•------ ------------------•-----------•---------------------------------- =-----------------------------,----------------------------- ------------------------ ------------------------------------___________________ ________ ____ ----_--------- _ ____ __ __ _ ___----.------------__--------------------------------- _________________________________________________ _ ________________________________________ A --- ------ _ _-_ -__ _- __ __ --------------------------------------------------------------------------------------------------------------- FINAL ______________-_____-__.____FINAL INS Of i_B -----------------------• --------- - Date--------/----=---,--� .-------------------- SAIN 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-9-21A ftevisep 1-57 F.P.CO.