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n APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ` Com u lcate `% tn t p iDate Issued .--.-----:__:.�:_._%* Application is hereby made to the San Jo i oc Health District for a permit to construct and install the work herein described. This application is made in compliance Witu t ace No. 549. (� `t d� Cd riF } ! r JOB ADDRESS TN LOC TIO `J a,,,'- - ---- -_A- ;---` ---------------------------------------------------- Owner's Name--------- r _ � �"' ----- Phone------------------ ------- {2 _ t' Address-----�r'4' Y�"�°.t!,fti i Fes•: T --- --_ " 1 :--_- � � � � � ��IJI S Contractor's Name--- --•- f G •, Phone Installation will serve: Residence Apartment House Commercial 0 Trailer Court 0 Motel 0 Other f Number of living units: 1----- Number of bedrooms -------- Number of baths __"4_n. Lot size _Z..1_ __l________._.____-_______________ Water Supply: Public system Community system ❑ Private ❑ Depth to.Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ej—Hardpan ❑ Previous Application Made: Yes ❑ No El"New Construction: Yes [a---1 o ❑ FHA/VA: Yes ❑ No ❑- - ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) k Septic Tank: Distance from nearest well__ Distance from foundation-__ --------------Material---(".o-------------------------------------- l� No. of compartments----- ----------Size._f'/_./_. .C___..=------Liquid de th_.___`�_," Capacity _________- Disposal Field: Distance from nearest well __-_Distance from foundation.......-_f__-.----Distance to nearest lot line----_u__f__- [ Number of lines__-___.`�_______ _______________Length of each line--____-��_(?___� ______-Width of trench._-_ __-___-.--------- Type of filter material_______-: _ --_-__Depth of filter material-___-__ _-____._.Total length-____,�_ `___________________________ Seepage Pit: Distance to nearest well-----------...........Distance from foundation--------------------Distance to nearest lot line----------------- F-I Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth----------------------__--____._ Cesspool: Distance from nearest well----------------- from foundation--------------______Lining material __________-_____-______-______ O ❑ Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------_---------------------_-------------Distance from nearest building_____-__-____--_____________________---_-. ❑ Distance to nearest lot line--.------ -----------------------------------------------------•-----•----•-----•------------------------------------------------------------ � w Remodeling and/or repairing (describe) 1 -- - ' --------- ------------- ----------- --------- --------------------- ---------------------- -- -- - p jj� ----- --------------�- ------_h ------'l'.--• -=/1.� '.``------------------------------------{ 1v) �� -..-- '�f'•_"'' .'.`',r - - - ----�=1-----`=-t-` ----'----•----------- --------------------- -. 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 en� regulations of the San Joaquin Local Health District. (Signed)-- ................ ✓t------------ :" 1 1 r 4 --------------------------------- (Owner and/Or Contractor) t By:..........-------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------ ------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- - - - - - -- ---------------------------------------------------•-. DATE---------- REVIEWEDBY------------------------------------------------------- ------------__----------------------------------------- DATE---------------------------------I------•---------_-------- BUILDINGPERMIT ISSUED------------------------------•--------------------------------------------------------------------- DATE-•------------------_-------------------------------------- Alterations and/or recommendations-------------------------------------------------•--------------------- --------------------------•-------------••------------------------•------------- ---1------------------------------ --- ---------------------------- ------------------------------------------.......... ----------------------------------------------- L -------•----`-- -- ------ Q ----- --- - Y - - • - :::: :: : :: �. :::::� ___ All FINAL -INSPECTION BY:----- Date--- --------- �'"�'2 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 , Revised 1.57 F.P,CO.