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l�U J APPLICATION FOR SANITATION PERMIT Permit No. ._l!5:. -—---- d V (Complete in Duplicate) _�z Date Issued . __.f/7 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 CATION l t---Z - -- __� ----------------------------------------------------------------------------------------------- Owner's Name-_,Z Phone Address----- --------------------------•-•--------------------------------- --------------- ------ Contractor's Name------------------ - ---------------•------------------------------------------------- Phone-------------------- Installation will serve: Residence PI.-7partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/__ Number of bedrooms -A-- Number of baths •__ Lot size ______________________ Water Supply: Public system R--c-ommunity system ❑ Private ❑ Depth to Water Table ey°r%ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2--pardpan ❑ Previous Application Made: Yes ❑ No J!r- New Construction: Yes ❑ No THA/VA: Yes ❑ No S- 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_____ __________-Material___.-_-____-_-__-___----_.-.-----.____,_____ 1Xjuflf compartments - -------------- ---- -----Size---•------•---------------------Liquid dept---•--------------------_Capacity----- ---•- Disposal Field: Distance from nearest well______'"'__'___Distance from foundation_____ _____ ___Distance to nearest lot line__._._..... Number of lines---------11-1.1_________-_______ _Length of each line___.__ ------------------- of trench.__� �!_________________ IS ,f / j i Type of filter material_ _Depth of filter material___ gee--_--___Total length-____-jO<�-/________________________ Gj Seepage P t: Distance to nearest well----------' --------Distance fromfou dation_.., ...f"..Distance to nearest lot line____.____ ! / Number of pits-----/___-_____Lining material__Xff-� ��Size: Diameter__, '___-__Depth....... /' Cespo Distance from nearest well______________Distance from foundation_________________.Lining material-------------------------------------- El Size: Diameter--------------------------------------De th---------------------._._-_---- -----------_Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------.--------------_.__.-_________-- ❑ Distance to nearest lot line------ -------------------------- ---------•------------------------------------------------------------ Remodeling and/or repairing (describe):4-------------- ----Q ----------------------------------------------------------------------------------•------------------------------------------------------- ----------------------------------•--------•------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------•-----------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------ 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 and regulations of the San Joaquin Local Health District. Signed) �____ Contractor C_a ( -- ----------------- -- --------------------------------------------- ) By:•-•----------------•------•---•-------••----•---•------- = == -----------------------(Title)---- ---�---------------------------------- (Plot plan, showing size of lot, location of em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- `---------------------------------------------------------------------- DATE--------1 "rl'= ------------------ REVIEWEDBY------------------------------------------------------------------------------- ------------------------------------------ DATE---------------------------------------.............------ BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------- ------------- DATE--------------------- ----------------------------------- Alterations and/or recommendations-------------------------------------------------------------------------------------------------------------------------------•----------------------- ------------------------------------_----------------------- •----------- ---------------------------------------------------------------------------------------------- ------------------------_------------------------------------------- ------------------------------------ --------- ------------------------------ ---------------------------- ------------------------------------------------------------------------------------------------ --------- -------------------------------------------- FINAL INSPECTION BY ----------- - ---- Date ro�� _" Q 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 F-P.CO.