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Permit No. APPLICATION FOR SANITATION PERMIT J (Complete in Duplicate) l Date Issued ---s_�Z�_.:_`_-7 -_ J 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. JOBADDRESS AND LOCATION__. fwV...-= -----------------------------------------------------------------------------------------------•---------------------- Owner's Name_ C-1'--v-a �----------------------------------------------------------------------------------------------------- Phone------------------------------------ Address......9�-53--41� ------------------------- Contractor's Name.. { ------------------------------------------------------ Phone, �_ _c5 � Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.,I__.- Number of bedrooms --9� Number of baths ._.l____ Lot size ------4d---4,_::?,_-VQ____________________________ Water Supply: Public system a 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 14 Hardpan ❑ Previous Application Made: Yes ❑ No §Q 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_________________Distance from foundation--------------------Material_______-____-_--___.__-____________-.__--____-._- ❑ No. of compartments------------------------Size_-------------------------------Liquid depth---------- ----------Capacity Field: Distance from nearest well-_-------Distance from foundation____410_ -------Distance to nearest lot line_S-/_______ ® Number of lines..... ---/----------------Length of each line____J-D_----------------Width of trench------�!y'°'_.---------------- Type of filter material----��.�_Q_�i._ ____--____Depth of filter material-___.!.IF__9_________Total length.____t----_________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line__-___----_-__-_ [A ❑ Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Depth--------------------------___--._ Cesspool: Distance from nearest well_------------------Distance from foundation--------------------Lining material__._____--____------____._._-____-__. (� ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. ;v Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____----_-____-__..___________-__._____._. (J ❑ Distance to nearest lot line----------------------•--------------------------------•--------------•--------•-------------------- Remodelin and/or repairing __-__--____ -_,. -----•---------•---------------•-------------•-•--------------•---------------------------------------------•--------------•------------------•--------•----- ----------------------------•------------------------------- -------------------------•-----------------------------------------=------------------------------------•--------------------- ..............----------- -----------------•-•---------------------------._ -------------------------------•-----------------------------------------------------------------------------------------•----------------------•----------------------------------------------------------------------------- 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 Sad (Si Joaquin Local Health District. (Signed) n'X(4 9 ) -•-•---- ------ ---------------------------------------------------------------------------------------------------------- --------(Owner and/or Contractor) i, By:.....------------------------- (Title)) 0( ------- (Plot plan, showing size of lot, locatio f system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------------------------------------------- --------------------------------------------- DATE-------------------------------------- ------- REVIEWED - DATE---------------------------- v BUILDING PERMIT ISSUED--------------------------------------Y-- ---- ---------------------------------------------------- - - -- --------------------------------....... DATE------------------ ------------------------.:----- ----- Alterateons and/or recommendations: - - -- ---- --- - .-- ------------------ ---------------------------------------------------- -------------------------------- ----j --------------------•------.-------------------------•-- -_---------------------------------------------------- -------------------------------------- ----------------------------------------------------------------------------------------------------------------------- - ------------------------------ ----- P�/j.xFINAL INSPECTION BY:. ---- ---- ------ "' Date--------- -4 --------------------------------- -------------- 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-9-21A : Revisea 7.57 F.P.CO.