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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Appl�tion i!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 N 549. JOB ADDRESS AND LOCATION__- .........---- �q�� ----------1_L?_ 11(f /�t� ------------------ Owner's Name - -- --------------------------------------------- ----------------------------------------- Phone-----------------•------------------ Address--------- / ------------------ Contractor's Name1'sr'------------ --------------------------------------------I-- ------ ------ Phone----------------------------------- - - Installation will serve: Residence &Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�___ Number of bedrooms _J_ Number,of baths/t Lot size __ /" _____________________________ Water Supply: Public system ❑ Community system Private Q^-Depth to Water Table'All ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe&-"Hardpan ❑ Previous Application Made: Yes ❑ No g?�New Construction': Yes @91�o ❑ FHA/VA: Yes F_t "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 frpm foundation----/0--------Mate ial___ No. of compartments____ _______` depth------- -- -___.Capacity-..,0_0Z4PQ_ Disposal Field: Distance from nearest well-----""-"._Distance from foundation.__*f®..,,_.Distance to nearest lot line-47____-__- 'Rtimber of lines---------- Length of each line '`> ®' - --- g .� -- sy ---Width of trench------:�.'lt�-------------------- Type of filter material_ZA.- ___ - Depth of filter material= ---_____Total length------,/�,f/_____'__.__________ Seepage Pit: Distance to nearest well------ -------Distance f�rjQrn foundation_...ZO.V4Distanc��to nearest lot line--- Number of pits___,-_-________Lining rnateriaL__/�B .Size: Diameter____ 3_ ____-Depth----- ------------------------ Cesspool: _�_`_____________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_________________-______._______. ❑ Size: Diameter------------------------1----- ------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------.___________-_._. ❑ Distance to nearest lot line--------------------------------------------------------------------------------- ------------------------------------------- 4 ,. Remodeling and/or repairing (describe):------------------ --------- -f -- ------------------------------------------- --- --------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------- --------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------•-----------------------------------------------------------•--------------------=----------------------------------------------------------------------------- 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. (Si ned 9 ) ------ ----- -------------------------- ------ Contractor) By:------------------------ -==------- --------- Title- (Plot plan, showing size of lot, location of sy in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----_r,-R_-d----------------------------------. --------------------------------------- DATE-----57�-2Q__'"-_�---------------------- REVIEWED BY--------------------------------------------- ------------------------------------------------------------------------------- DATE-------------------•-------------- BUILDINGPERMIT ISSUED_------------------------------------------------------------------ ------------------------ DATE------ ------------------------------------------------ Alterationsand/or recommendations--------------------------------------------------------- --------------------------------....................................................... ------------------------------------------- / D �-> t --------- ------------------ ------ ----- T� :...----TAI.'.KS----'4----.----- . O---------Jh - f --- -' --- a----- --------------------�-------------------------------------- FINAL INSPE ION BY:---- ,?? k --- ---------- Date---_57-ZU- --- ------------------- ------------------------- 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 FP.CO.