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V, ivSrt 1�/fty /W11 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ___ V. _ Date Issued ___ _? Application is hereby made to the San Joaquin Local Health District for a permit to constrQF�'a d i 11 t here' ed. This applicatiod,is made in compliance with County Ordinance No. 549 JOB ADDRESS ANDATION--:- °/ ---- ---_-- -___- ------------- � --------------------- -------------------- -- -- ----------- ---- Owner's Name ±------- -------------- - -------------------------------------- Phone ------------------- ---- 'f O v'�+ -- Address__. !� �//1�� ----- f+�' -- - -- ••----------------- - Contractor's Name-------- c- --r------J -- ---------- ---- ---- Phon ;�., Installation will serve: Residence kApartment House ❑ Commercial ❑ Traiil/lpZ Court ❑ fMotel 0 Other'[j � Nurnber of living units: _.�_°_,Number of bedrooms��Number of baths Lit size ___I --_-------- 1 -- ________________ ! Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabl __ ft. Character of soil to a depth of 3,feet. Sand 1771 Gravel [j Sandy Loam Clay Loam E] Clay n] ,A'dobe Hardpan ❑ Previous App[icai"ion Nlade:�Ye;❑. No New Construction: Yes No ❑ FHA/VA: Yes ❑` No .k TYPE OF INSTALLATION AND SPiCIFICATIONS: (No septic tank or'cesspool permitted i p6blic s er is available within 200 feet.) z `! �* Septic Tank: Distance from neares we —Distance frg� fo�u}�,dpfion__�®__-_.___Mat 'al, s e _ _ __________ __ _______ No, of compartments______ ___rc__5ize_ _____ _�!s0___._Liquid dept______ Capacity__ ?W ---- N p ___._. I Distance to nearest lot IY _ Dis os Field: Distance from nearest well_ Distance from foundation_ Number of lines__________ _ _ ____ __- Ler:gth;of each line________ ! _ f/ Width of trench__ ---------- Type of filter material-_ _ ._ ___ __�Depth of filter material----�(�-_f-_--Total length_______ � Seepa a Pit: Distance to nearest well,A ____:Distanc o f ndation---AV.:_.___.Distan.�,p to nearest lot line�5;�7----- [ ,Number of pits------ _-----------Lining material ----Size: Diameter--- ..____Y_ __Deptn_. aj ________.____.-_- ...... Cesspool: Distance from nearestfwell-_--------------- Distance—from--foundation___'___:__._.___.Lining material-_______.________________------_ ____ ❑ Size: Diameter--------------------------------------Depth------------------------------------------;---------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_+-----------------_______----------F-----_,Distance from nearest building-----._________________-_-----________._. ❑ Distance to nearest lot line-'--------------------------- --------- Remodeling -------Remodeling and/or repairing (describe):-------------------------------------- `s -----------•-•----- ------------------------------------------I---------------------------------- ---------------------------------------------------------------------------------------- f . ------------------------------ ---------------------------------------------------------------------------- -----------------------------------------------------------------------•--------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State s, d rules and regulations of the San Joaquin Local Health District. {5i ned g )------------------ ---�--`.zt�..------------------------------ ------------- -------- Contractor 1 f 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 APPLICATION ACCEPTED BY DATE---------•-- ----------- ---- -------------------- -- ----- -- ------------ ------------------- ----- REVIEWED BY DATE-------- --- - ----- - -- -------------------------------------------------- BUILDINGPERMIT ISSUED..-----•----------------- --------------------------------------------------------------------------- DATE--------- ---- --- ---------------------------------------- Alterations and/or recommendations-------- -------------------- -------------------------------------------------------------------•------------------ ----•-----------------------•------------ -------------- ---------•-------- --------------------------------- --------------------------------------------------------------------------------•----------------------•---------------------------------------- ------------ ---------------------------•--------•--------------- --- ------ ----------------------------------------------------------------------------------------------•--------------------------------------- ---------------------•- •-----•------------ --------------------------•------------------------------------------------=----------- ----------- ----------------------------------------------------------------------------- FINAL INSPECTION ,BY: C -,Date-- ---------------- ------------------------------------------------- `SAN JOAQUIN LOCAL HEALTH-DISTRICT 130 South American Street 300 West Oak Street, 132 Sycamore Street 814 North "C" Street Stockton, California Codi, California Manteca, California Tracy, California ES-9-2M1 , Revised 1-57 F.P.CO.