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i A \ J APPLICATION FOR SANITATION PERMIT Permit No. "\ (Complete in Duplicate) 'J / Date Issued .......J__----5. . 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. jf- �y JOBADDRESS AND L ATION--- ----- -------- -------------------- -------------------------------------------------------------------------------------- ----------------- �� Owner's Name--- opolff-------------- 1 ............,,tt ------------ Phone------------------------------------ Address------I.7u /2 I . Contractor's Name----- - ____________ --------------------------------- Phone.........--------- Installation -5_-_.Installation will serve: Residence ❑ Ap ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ... Number of bedrooms _ ___ Number of baths _1_____ Lot size ------ d_ __ a------_____________ ____________ Water Supply: Public system (A Community system ❑ Private ❑ Depth to Water Table r�d ft. Character of soil to a depth of 3 #eet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe 64 Hardpan ❑ Previous Application Made: Yes [] No ❑ 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---•------------------ Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- 0 Number of lines___________________________________Length of each line------------------------------Width of trench________________-________:_-_______ Type of filter material------------------------_Depth of filter material_- -.---_____________.Total length.......-----------------------__-__-__--__ Seepage Pit: Distance to nearest well_____ _______ ________Distance from foundation___ _d..........Distanwe to nearest lot lie____ __11_______ Number of pits_______I--------------Lining material-___ ------Size: Diameter------- G_____.----Dept h---457__________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 1-1 Size: Diameter------------------------- ------Depth--------------------------------------------------_Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- 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, State laws, and rules an regulati of the San Joaquin Local Health 'strict. t (Si ned 9 )------------------------------- ------------- ----- ----- ,------------�-�- ----- ----------- ---- -�"�----------(Owner and/or Contractor) --------------------• -4 ---- --------------- -------------------- Title Gt.✓1------ (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 A APPLICATION ACCEPTED BY--------IPI-1-0-11--------------------------------------- ------ DATE--------1 ��/ ��------------------------------ REVIEWEDBY-------------------------------------------------------------------------------------- -------------------------------------- DATE---------------------------------------------- ------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----•------------------------------------------------------ Alterations and/o ecommendations--- ------------------ = - --- -------------------- ---- ------- ---------------------- - - - ----------- tk ----------------- l--- ` -----� --` ...t _.______--___-_____--___ ___ ------------------- _________-_________________-_________________----____________________-___--___-__-----_______----______-__-_--_-_____-__- -_____ ___ _______c-____-___----___-_________-_-____-__-____-_-_-_______________-___-_______-__-___-____-_._____-__---__-__--___-__..___.._. FINAL INSPECTION BY- - teQ-- -------- -- ----- Date--------- f r cr ------------------------------------- SAN ------ ----- ------ 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 ; Revised 1.57 F-P.CO.