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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 Ordinanc��9. �!�/ JOB ADDRESS AN LOCATION-------7...---- ------ �-/G ----- Owner's Name- r� ---------- it/ -------------- Phone------------------------------------ + Address------- a -1S__ -_---- Contractor's Name "' ------------------------ Phan, Q , Installation will serve: Residencepartment House E] Commercial E] I Trailer Court ❑ Motel E] Other ❑ Number of living units: __ ___ Number of bedrooms -vZ Number of baths - _____ Lot size -_-_- Water Supply: Public system E] Community system E] Private �epth to Water Table/A- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] 6Clay Loam [��ay El Adobe 0 Hardpan ❑ Previous Application Made: Yes F1 No �ew Construction: Yes El No [J'�fHA/VA: Yes [71 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) +-- tlLank; Distance from nearest well-----------------Distance from foundation--------------------Material____________________--______________----___--__. No. of compartments- ------ s-----Size-----•-------------------------Liquid depth--------------------------Capacity----------------------- Disposal Id- . Distance from nearest wellJO______ Distance from foundation- Distance to nearest lot line----4_`�_________ Number of lines_-_._____1____ Length of each line_______S________----Width of french-------- 7_ __ ryiI ._..._...�...... Type of filter material.�_r_- _ Depth of filter material______ Q_________Total length_______________________-0 _ 47 _-_-__. W Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____________..._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth_ ------------------ 0j Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----.________._____.________-______. ❑ Size: Diameter-------------------------:------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well ____________________________________________....Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line------ - ----------------------------- ------------•-'----____-- p kl Remodeling and/or repairing (describe)---------------- -------------------------------------------------------- ---------------------- -------------------------------------------------------- -----------------------------------------•------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- �} ----------------------------------------------------------------------- ------------- -------------------------------------------------------------.._._.---•--------------------------------•-------------------•----------- •� ------------------------------------------------------ ------------------•--------•------------------------------------------------------------------------------------------------•---------------------------------------- I here6y ertify hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to I s, ano rules and reg tions of the San Joaquin Local Health District. (Signed) -- -------- (Owner and/or Contractor), ------- --------- ----- - ----------- --- ------ Ely:----------------•---------•--------6UA9��----- - ----------------------------------{Title)---- � �---------------------..._..--.............. (Plot lain, showingsize of lot, location of system in rein to wells, buildings, etc., can be placed on reverse side FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------------------------------------------------------------------- DATE °� --------------------- ----------------------------- REVIEWSY - ---------------------------------------- ----------------------------------=------ DATE----4� BUILDING PERMIT ISSUED------------------------------------------------- -------------------------------------------------- DATE Alterations and/or recommendations-------------------- �------------.------•-------- ----- - ---------- ------------------------------------------------------------------------------------ ---------------------------------------------------•------------------------------------ ----------------------------------------------------------------------•----------------------------------------------------------- ----------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------•-------- --------------------------------------------------------------- -------- ----- ---- -------------------------------------------------------------------------------•----------------------------- - -- FINAL INSPECTION BY:.----- •----- 'f� Date- SAN �. +�` Ll 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-4--2M . Revisea 1-57 F.P.CO.