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1 APPLICATION FOR SANITATION PERMIT Permit No. .--_! k2_S____ (Complete in Quplica+e) // Date Issued ____�l--s Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicafion is made in compliance with County Ordinance No. 549. 'd JOB ADDRESS AND LOCATION.- �� -------- - - -------1'-- ---- -------------------------------------------- ---•------------------------------- 4&Owner's Name---------- --------- ------ - --------------------------------------------- Phone------------------------------------ Address -------------------------------------------------------------------------------------------------------------•----- Contractor's Name = = -- -----� --------------------------------------- Phone---------------------------------- -------------------------------------------------- will serve: Residence�Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __. __ Number of bedrooms __42 Number of baths -_/___ Lot size -6-- _______________________ Water Supply: Public system Community sys+em El Private F] Pft. Depth to Water Table -./_ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 9 No ❑ PHA/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 founds+ion.--�1�___`______.Materi�l_�__________ _______ No. of compartments--- Size_ v__�_ y ^Liquid de th_________�f____.________Capacity____,?,0_O_ Dispo al Field: Distance from nearest well_"�r Distance from foundation__a`�_ __f_____Distance to nearest lot line--- -------- Number of lines------- Length-of each line_____--___.Width of trench......1__y_ ef Type of filter ma+erial__ ------Depth of filter material___-f_ ------------Total length--- Seepage Pit: Distance to nearest we ---_ __Distance rorrfoundation__ -_ --------..Distance to nearest to ne___ Number of p,+s_,----`------------Lining material- - Diameter__--- --- -)--'_e'_----Depth------ --------------------- \ Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining material___.__._.__--______._______.__-______- 1 ❑ Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearesf building------------------------------------------ ❑ Distance to nearest lot line------------------------------------------ -------- ------------------ -------------------------------------------------------------------I—- Remodeling and or repairing describe ---------------. __ ��_ _ __ ------------- ---W_X ---------------•-------------------------------- I hereby certify fha+ 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) __ Owner and/or Contractor --------------------------- By:-------------------------------------------------------- --------------------------------------------------------(Title)----------------------------------------- (Piot 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-__- �` - -- - --- -------•------------ BUILDING PERMIT ISSUED---------- ----- - - -- ------ -------------- - ----------------------------------- DATE------------------------------------------------------- Alte ions and/or me tions: - r - ----- -- --- --:: --------------------------- -------- ------- -------------------------------- - --- �4 -------- --- ----- . --- ------` --- - ---- -- ----- -- - -- ------------- - -- -------------- ------------ ---- t-- A -------- -------------------------------•------------- --------------------------------- ------------------ Date--- // ---------------------------- FINAL INSPECTIO BY:.- --- - - - ---- �6---�--�f�-.-- - ------ - SA 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-4-2M Reviseci 1.57 F.P.CO.