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APPLICATION FOR SANITATION PERMIT Permit No.(Complete in in Duplicate) Date Issued I 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. 0,(77- O�p---�� JOB ADDRESS AND OCATION �;;� -------------------- = G- '--------- rvJ+ �-- -)--- --------- ---- ---- Owner's Name---- ----------- Phone------------------------------------ Address--------1,1.V - zL,/-----------•----------------------------------------------------------------------------------------- Contractor's Name__li! �xt r4t _ _ 'y�'2'- �'-1 /'ilio I Installation will serve: Res ❑ Apartment House ❑ Commercial 41 Trailer,Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths -------- Lot size Af- '•4ldrel-------------------------------------- A Water Supply: Public system ❑ Community system ❑ Private Z Depth to Water Table SD ft Character of soil to a depth of 3 feet: . Sand ❑ Gravel ❑ Sandy Loam 4 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ , No ❑ 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.) Septic Tank: Distance from nearest well/r .__--__Distance from foundation_j;!'^_-C,D_-------Material___ --__--�_____.____-__. No. of compartments----- ----------------Size_r} _>�----------------Liquid depth-----47-------.--------Capacity-_!_-----_------ (J� Disposal Field: Distance from nearest well-4-0-----.._.Distance from foundafion__`�a________---Distance to nearest lot line__/_�'_____- 44 Number oflines -----.----- -Length of each line----------��--------------Width of trencho_3�"----.---------------- 101� Type of filter mat eria 4 °Depth of filter material---!_----------Total length___ ___________________________________ Seepage Pit: Distance to nearest well---_------------------Distance from foundation------------.'-.__.Distance to nearest lot line---- ------------- =11 ❑ Number of pits-----------------`----Lining material---------------:-------Size: Diamete`r-----------------.-----.Depth--------------------------------- - Cesspool: Distance from nearest well-----------------Distance from foundation------------_.__----.Lining material-_________._-__________----__-___.__.. ❑ Size: Diameter-------------------k------------------Depth---------------------------------------.---="r-------Liquid Capacity----------------------------gals, Privy: Distance from nearest well.--I------------_--------------------------------Distance from nearest building--------------------------------------- ❑ Distance to nearest lot line------------•------ ----------------- -------------------- ----------------------- ----------------------------------------------- m, Remodeling and/or repairing Idescribe}:... -' " -` --------------•------------------------------------------------- ------- ------------------------------------------------------ -------------------------------------------------------------------------------•--------------- 1 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. �7,J Owner and/or'Confrii'�e l d { lCG (Signe - - ---------- ---- - $y:.- L ----------------------------•---------------------------------(Title)---------------------------•------------------------------------ (Plot plan, showing size off 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-------------------------------- --------------------- ------- DATE_-----------•----------------------------------------------- ' BUILDING PERMIT ISSUED-------------------------------------- ------------------------------------- DATE-------------- .-------------------------------------------- Alterations and/or recommendations:--------=---------- ----------------------------------- ----------- ------------------------------------------------------•------------------ --------------------------•--------------------------- ---------------------------------------------- --------------------------------------- -------- ---------------------------------------------------------------------------- ---------------------------------------------------------- ----------------------------------•-------------------•-------•------------------------------------------------------------------------------------------------ r FINAL INSPECTION BY - - •--- < ----------- Date---,;----- ------------ -------------------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Streat 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F,P,CO.