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{� APPLICATION FOR SANITATION PERMIT Permit No. ._�/.... �� v (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 LOCATION------��~/ j--------457-ic �tf/it 0Z_"� Owner's Name--------� +�' - -• Phone.............. _ ----•- Address------------ i 0!�_.....---- •---•--- Contractor's NameF"-------------------------------------------.......................................-• Phone_...___._---------............ Installation will serve: Residence P!r"rApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ / o � Number of living units: Number of bedrooms 4;Z-- Number of baths __l__ Lot size ______________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table l�+tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe 6—rardpan ❑ Previous Application Made: Yes ❑ No g;j` New Construction: Yes ❑ No R?-`NA/VA: Yes ❑ No 5+_ 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__ Ncompartments .4' .__Liquid depth___�jF _ ______Capacity_.__ - No. of com -- p o2._-- ' Size__ __ Di osal Field- Distance from nearest well Distance from foundation.�.A -Distance to nearest (pt 114 Number of lines. --1 7-` Length of each line..... If- J Width of trench ,t'G' Type of filter material_ _ �pepth of filter material- ------------/f�� Total length.....�-i. ......... ---------- ?e,gple Pit: Distance to nearest well-___ _._ ________Distance from foundation__...__ ..__..Distance to nearest lot lineNumber of pits _. ___•-_-______.Lining material__ Size- Diameter_________•_____________.Depth_,__--- .____._ Cesspo : 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 re air' scr' - ......... -----•-•-•• -------••----------------------------------------------------------- -------- --•---- ---- -................... ----------------------------------------------------------------------------------------------••-••-••----•-•-----•-----••-••---•--•-----••---•------------•----------•-----------•••---•----•-----------------------•--- 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 re ulations of the San Joaquin Local Health District. (Signed)............... = •yG 'U'`-- ` J (Owner and/or Contractor) ey:. - Irtle) " (Plot plan, showing size of lot, loc of system in relation to wells, buildings, etc., can be placed on reverseesl� ). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - ------ -------------------------------------------- -------------- ------ •------- DATE---•••-- •---- ------------------ DATE................ REVIEWED BY-------------=------------------------------------------------- - -- -- ---------------------- •--•- BUILDING PERMIT ISSUED------------- -------------------------- --- ------. DATE ._._.------•r Alterations and/or recommendations ---_--- -- ------ --- -- ••-•--•--••--------•••-•---•••. ................... �---_..._ ...-- •••---••--...,.. •------ ---------------------------------------------------------------- -- -------------------------------------------------------------------••••• .................................................. ---------- FINAL INSPECTION BY:.-DU^^----- ----------- --- - ---- ---- Date------t.£.%__ ..__�.. _ SAN JOAQUIN CAL 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-9-21A . Revised 1.57 F.P.CO.