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APPLICATION FOR SANITATION PERMIT Permit No. _1.795_-_ (Complete in Duplicate) pate Issued C _2_1 � ,. ---------- 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 N 549 JOB ADDRESS AND CATION.O_f i -----�� &4----�Vw--------- = --- --- Owner's Name------ -- Phone---------- - ---------------- Address-------- j -- ,�i� / '- Contractor's Name ' , -�C --------------------------------------------------------------------------- /�_ K ------ Phone--------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial 0 Trailer Court ❑ Motel '❑ Other ❑ Number of living units: __0.__ Number of bedrooms __ Number of baths __, .r Lot size -- �_____________________ Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table __#0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loarri`Z?"'Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes F❑ No Pk*- New Construction: Yes [�No ❑ FHA/VA: Yes RNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) . ... A -� Septic Tank: Distance from nearest well,_"�___Distance fffom foundation_ ____-----___M�/aterial_________ _____!l'1'�__________._._________. No. of compartments------- ------ - --Size--- l _X_ �_-.---Liquid depth---_f_p_/----------Capacity---- '------ o Disposal Field: Distance from nearest ell----_":._____.Distance from foundation__ �__�Q________.Distance to nearest lot line__0_ ____- �� Number of lines___.________ ___________ Length of each line________ _ �� �r� ---- - Width of trench of filter materiaL_� __Depth of filter material_---"-� !i .Total length___-----� _�---------------"- I Seepage Pit: Distance to nearest well----------------------Distance from foundation---.---------------.Distance to nearest lot line-----------_----_ r ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------------------_- P Cesspool: Distance from nearest well-----------------Distance from foundation-----_---------------Lining material___.__________.________.________- \ r ❑ Size: Diameter--------------------------=---`------Depth----------------------------------------------------Liquid Capacity -------gals. Privy: Distance from nearest well______________________________________________Distance from nearest building_____...______.____________-_---__-_____ ❑ Distance to nearest lot line-------- - ------------------------------------------------------------------------------------------------------------------------------- t - Remodeling and/or repairing (describe)----------------- ------ 4e�--------------------- ----------------------- I -------------------•-----------------------------------------------------------------------------------------••----------------------------------------------•---------------------------------------------------------------- I here6y 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 the San Joaquin Local Health District. {Si ned 9 )-----------•----------------- - - ------- --- -- --- ----- - - - ----- � - -- --- -= - ---- ---------- Contractor] By:------------------------------------------------------- --------------------------------------------(Title)- -------------------------- (Plot plan, showing size of lot, location a stem in relation to wells, buildings, etc., can be place on rev se side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ __ - -- --- - - - - - - DATE --------------------------------------------------- REVIEWED -------------------- --------------- -- - REVIEWEDBY--------------------------- ---- -- --------------------- -------------------------------------•-------------------- DATE----- BUILDING PERMIT ISSUED._.-------- --------------------------------------------- ---------------------------------------- DATE-------- ----------------------------------------------- E Alterations and/or recommendations--------- ------------- ------------------------------------------------------•-----------•----------------•------•--------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- •-------------------------------------- --------------------------------------------- •----------------------- ----- ------------------------------------------------------------------------------------------------------------------------------ ----------------- -----------------------------•-----•------------------------------ -------------------------------------------------------------------------- --------------------------------------------------- ----------- ( FINAL INSPECTION BY:. Date � — _ ----------------------:--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stocic'ton, California Lodi, California °`' - Manteca, California Tracy, California E5-9-2M Revised 1.57 F.P.CO.