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APPLICATION FOR SANITATION PERMIT Permit No. ___________________ r c- (Complete in Duplicate) Da+e�sued _._--_--- ---�-- ._ .d 05'e-0&v- - N 1 7?E�JStD.J-.,GI - s pp,cation is hereby made to the San Joaquin Local Health District for a permit to construct and install th or erein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATi.ON__0�C<4----rf, f _ I/h--�L�-2v'G' �(, _� - --------�%�c Owners Name-------------��--�--•--=--_�-------- --fl.. ----� ]..�----• . Phone--V- Address hone--V- -------- --- '��=--� Address------------------------•-•------ '' ��f �;` --'�'------ ----=--------------------------------------------- Contractor's Name-----------J,�:h1_�----------------------------------------- - ----------------- ---------------------------------------- Phone---------------------------------- Installation will serve: Residence [0f partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ -`�`---------------- Number of living units: ---- Number Number of bedrooms _�-- Number,�off baths __ Lot size Water Supply: Public system ❑ Community system ❑ Private 2—llepth to Water Table -_-_-_-- ft. �^ Character of soil to a depth of 3 fee+: - Sand ❑.. -Gravel F] Sandy Loam lay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ElNo 9""New Construction: Yes ta"No ❑ FHA/VA: Yes ❑ No ®' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if pubic sewer is vailable within 200 feet.) l �' Septic Tank. Distance from nearest well-, __-/--- Distance from fou`dation_-�_��___-___-.---Mate�ial., _- �` --- - ---------- ` Size-_4-1_�-_,�__X _ Liquid de th-----ZI __..._______Capacity__ No. of compartments r� a q d p. !- - ,ield: Distance from nearest well___153`4-Distance from foundation__- -------_.Distance to nearest lot line____ ___ Disposa _ r ® Number of lines------T;`-�---------------------Length of each line------1, --`}'-t�___--_-- Width of trench--- -`(_`=--------------_----- .; Type of filter material---__n4r4l _------Depth of filter material__�_r---------------Total length_______, Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits---------------------Lining material-----------------------Size: Diameter----•------------------Dept h--_...--------------------------- �1 t Cesspool: Distance from nearest well.-----------------Distance from foundation____-..--.--__--_-.Lining material_--________--------_---.---__-_-_---. J ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------- --------Distance from nearest building------------------------.----------------- ❑ Distance to neares+ lot line------------------------- --- --------------------------------------------------------------------=-------------------------- - Remodeling and/or repairing (describe):---------------------------------------------------•----------- --------------------------------------------------------------•------------------------ ---------------------------------------------------------------------- ------------------------------------------------ -------------- ------ ---- ----------------------------------------•---------------------------------------------------------------------------------- I hereby 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. (Signed}__ _!_ .z. __}� ��n� °`'-- ------------------------------------------------------------------ ----- (Owner and/or Contractor Tale (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). z FOR DEPARTMENT USE ONLY DATE------ APPLICATION ACCEPTED BY---------------------- �-------------- -------------------------= r :.__� REVIEWEDBY------------------------------------------------------------------------------------------------------------=------------- ----- DATE--------------------------------------------_-------------- } BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ Alterationsand/or recommendations----------------------------------------------------------------------------------------------•--------------••------------------------------------------------ ------------------------------------------------------------------------------------------------ ---•--------------•------------------------ .. ---------------------•---------------------------- ---------------------- ---•------------- 3 "S 7. - ------------------------------ --- FINAL INSPECTION BY:.-_-,�,�``Gly'1�€.� r-' ----------------------- Date. r SAN 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-9-2M , Revises 1.57 F.P.CO.