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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 Ordinance No. 549. JOB ADDRESS AND LOCATION________ Owner's Name----------- -�1-- Y I' t -------------------------- ------ Phone------------------------------------ Address----------------------------- ---••------------------------------Address------------------------•---- 6.1-7-------'-----------�- -- ------------------------- ---- -------------------------------------------•-------------------------------------------------------- Contractor's Name-----------------------�--'----q------- ✓-(C- ---X------------------------------------------------------------- Phone.----)-id---Z Installation will serve: Residence ©-'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I---- Number of bedrooms -.3--- Number of baths ___ ___ Lot size ------- .c}_.K_I_QV__________-_________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe.�ardpan ❑ Previous Application Made: Yes ❑ No Ej-'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.] , Q Septic Tank: Distance from nearest well_)!:�'-_Distance from foundation__J0_------------Material __- ___________________- [}� No. of compartments-----7 -------Size--- -----------Liquid depth------�/----------------Capacity__44j- 0---------- i Disposal Field: Distance from nearest well.._��Distance from foundation____1-V-----------Distance to nearest lot line._. _______. � Number of lines--------�-----------�--`-- Length of each line---1 t� �--Y�+---.Width of trench...... (-�.------------------- 0'0 Type of filter material___�~ __.______Depth of filter material____),$_'_----------Total length.----Z.iY4__-_______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to-nearest lot line__-____._________ ❑ Number of pits----------------------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------------------------------------------------- from nearest building.________------_----------_-------------- �' I ❑ Distance to nearest lot line--------------------------------------------------------------- --------------------------------------------------------------------- i Remodeling and/or repairing (describe):-------- ---------------------------------------------------------------------------•---------------•---------------------------------•------------- E ---•----•--------------•--•----•-------•--- -----------------------------•------ ----------------------------•---•--------------------------------------------------------------------------..------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------=-•---------------------------------------------------------------- -- -- •------------------------ -------- - --- -- - ------------------------------------------------------------------------------------------------ ------------ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County rn nces, State law , and rules and regulations of the San Joaquin Local Health District. ordinances, ` (Sign `�'`� {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 APPLICATION ACCEPTED BY--.-- -- -CV------- - --------------------------------------- DATE----1d.�_ f REVIEWED BY-------------------------------------------- -------------------------------•----------- ----- .----- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:-_____. ----- -------------- �� -------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------•--.-------------------------------------------------------- -----------------------------------------------------------•---------------------------------------------------•---------------- -----•--•-------------------------------------------•------------------ --------------------- FINAL INSPECTION BY:---------------------------------------------------------------- Date--------------------------------------_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Reviseci 1-57 F.P,Co.