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APPLICATION FOR SANITATION PERMIT Permit No. ._. lCa--____ / ( S l (Complete in Duplicate) � / �r . Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wo herein ed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION!_ ____ __ njel_`tti + > ! , � Ix Owners Name = 2� - '�G ------------------------ -------------------------------- Phone--------------------------------- Address------------- ----•-----••----------•---------Address------------- z"�__... l '? ------�r- .�' ��•--------------------------•---------------------- Contractor's Name------------••---_- .JUL � Phone. '_S :. 4� 1 ... Installation will serve: Residence ®--A-partrrient House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __!.__ Number.of bedrooms = __ Number of baths I--- Lot size ---.__�_f ----------------------- Water Supply: Public system ❑ Com11 munity system ❑ Private Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑—Gravel.❑_Sandy Loam_❑„.CIay,Loam I] Clay ❑ Adobe [}'Hardpan ❑ i Previous Application Made: Yes ❑ No P+ew Construction: Yes D�No ❑ FHA/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-neatest wel __ _ ------Distance from foundation___ ------ -.Material ___Lr :-_---- Q� No, of compartment s---------'Z---------------Size__-_�?..4_Y-3-6-------Liquid depth---- ---------Capacity---- Y ". ------- Disposal Field: Distance from nearest well#_-`~?�'4__/-_Disfance from foundation____---- _.Distance to nearest lot line______5_: -_F UK Number of lines----------/----------------------Length of each�line..... '�'''_��*"-.Width of trench____ r �_:'___-----_---____ Type of filter material___!c_�} :��-Depth of filter material-----1_�- _------Total length-----Z�___________________________ Seepage Pit: Distance to nearest well_ _ _ S _f istance fr m foundation____ _ .Distance to nearest lot line____'. , ® Number of pits----- - - --------------Lor --. Lining-material Diam �-- }eter-,,-- -----------Depth-----' - F_________---------- Cesspool: Distance from nearest well----------- from foundation_______________ +-.Nwining material_________._____._____________________. ❑ Size: Diameter------------- - -------- ----------- Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------r-------------------------------Distance from nearest building---------------------------._--__________- ❑ Distance to nearest lot line------------- \l� A N Remodeling and/or repairing (describe)----------- --------- -----------1---------------------------------------------•---------------- -••-------------------------------•-------------------- `� ---------------•--•----•-------------------------•-----------••---•-----------•--------------------------------------•----------------------------------------------------•---------------------- -------------------------••----•--------------------------•--------=---••---------•-----------•--•-----------------------••--------------------------------------------------------------•---- •---•---._.. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S+ate,llaws, and rules, d regulations of the San Joaquin Local Health District. -� (Signed) -- -- ---------�-----r---��-�----� - ----- --------------------IOwner and/or Contrac+orl ^ _ By:----------------•-----.......----• .:}: - ._.. .�' _ " (Ti+le). _ --------- (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 ---- -- -------- ---- --- ----- DATE REVIEWEDBY--------------------------------------------- -----------5--- ------ ------------------------------------------------- DATE----------------- f BUILDING PERMIT ISSUED---------- --------- --- ------------------------------------------------ DATE------ ----------------------------- s:Alterations and/or recommendation _ ---------y----- ----------J`--`- •--_ ----•-'--------- -------- --------••-------••--------- _. / ... ------ -f----------- . ti - ----•- -- , ------ - --------- ,--- f.. .. --- --------S----- ----- • - �FINAL INSPECTION BY - ----ff---- - - Date--------- ---I-- -- ------------••--•------- SAN JOAQUIN LOCAL HEALTH DISTRICT 13o South American Street 300 West Oat Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO. F r