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APPLICATION FOR SANITATION PERMIT Permit o. .___ .3.?..._ (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 County Ordinance No. 549. JOB ADDRESS AND LOCATTIION------.._lI 7------------------ e0----------- - .-----------------------------------__- - Owner's Name-------- f' -----------------c4 ==��`�' --------------------------------------------------------------- Phone Address -141-.1745- ---�------ - ------ ---------------------------------------------------- - •------------------•------- Contractor's Name---- •-- --------- ------------- .................... Phone................................... Installation will serve: Residence 0/Kpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:,l____ Number of bedrooms _-__'2--f1u—rnber of baths __/___ Lot size __ _____________ _____ Water Supply: Public system Community system (] Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: Yes ❑ No 62_,New Construction: Yes 92—No 2 FHA/VA: Yes ❑ No K, 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_ Distance from foundation__-6.L`1 ___.Material_ 9 No. of compartments-,.2Size �'�-_ .... Disposal Field: Distance from nearest well Distant f�EwJn Distance to nearest lot line ❑ Number of lines________________ellinag e each lbD__�..---- __._.Width of trench. -_-___________.---------------- Type __-• _-_____-_ Type of filter material_____ epth of filter material_______________________Total length_____________________________-_______-____ f �� Seepage Pit: Distance to nearest well-- istance fr m foundati ____ .........Distance tp nearest lot line___�'" _._.- Number of pits.-..__ _-_-_ terialL_. rc _ �___Depth__,�.,� eter 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-------------------- -------------------------- ----------•----------------------------------------------•----------------------- 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, Stat , and rules and regulations of the San Joaquin Local Health District. ( igneS d)----- - ----- -- ----- ------- (Owner and/or Contractor) By: = -_------------------------(T'itle) `... (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 APPLICATIONACCEPTED BY-------------- ------- ---- ----- -------------------------------------------------------- DATE-----. .............................................. REVIEWEDBY--------------------------------------------------------- ----------------------------------------------- ----------------- DATE-------•- BUILDING PERMIT ISSUED---------------------------------- - DATE_----------•- - - - - - Alterations and/or �ommendatio - - -----------`•------------------------------------------------•------------------- v�1 � ? --•----------- - .--- -- ........................ ----•----------------------------•...--------.---.----------..---------------------------- -----------------------------------------------------------------•--------------•---.._-------------- .-•--._._-_._ ----------------------------------•--------------------•- ------------•----------- ---------------•--•--.--- -- ..............................-----------------------------._-------------••--•------------- FINAL INSPECTION BY:--------/ ,4 .�------------------------------- Date-------------------------------- 5 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 . Revisea 1.57 FY.CO.