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APPLICATION FOR SANITATION ,PERMIT Permit No. <br />(Complete in Duplicate) <br />Date Issued <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br />This application is made in compliance with County Ordinance No. 549. <br />JOB ADDRESS AND LOCATION--- --- ------------ -----a--{ -----i,-O•t� ----------- -1-----T-------� � -------- ------ ------------------ <br />cc <br />Owner's Name------ (A'34E------ � a --------fir 01( L� Phone: <br />Address--------------- Z ka----- t h{�L----------------------- --- ------•--------•- <br />Contractor's Name .O_i14� -------------- Phone ----------------------------------- <br />, <br />Installation will serve: Residence [!J Apartment House ❑ Commercial ❑' Trailer. Court ❑ Motel Other ❑ <br />Number of living units: __--I_-_ Number of bedrooms _ Z. Number of baths ... Lot size __.__ZU__x.JtA_r4--_____- .-_-___ _.__ <br />Water Supply: Public system ❑ Community system ❑ Private R( Depth to Water Table _jb. ft. <br />Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam (N Clay-❑- Adobe ❑ Hardpan ❑ <br />Previous Application Made: Yes ❑ No ®• New Construction: Yes ® No ❑ FHA/VA: Yes ❑ No j <br />TYPE OF INSTALLATION AND. SPECIFICATIONS: <br />(No septic tank or' cesspool permitted if public sewer is available within.200 feet.) <br />Septic Tank: Distance from nearest well--:;' ------- Distance from foundation ----- I_Q__-------- M <br />terial__�i <br />No. of comparfiments___..Z_.-__.__.._Size___3x4�____•___Liquid deth_______________C:1 ------ <br />n <br />_® p_14 <br />_1►`►4lr�QQ�, <br />Disposal Field: Distance from nearest well__.�___Distance from foundation --- 1(Q-_ -------- Distance to nearest lot line___________. <br />® Number of lines______,___, _ __.__ ___ Length of each line.______ _ Width of trench ----- Z_______________________ <br />�. - f� 4 �i-------- <br />Type of filter material----1------Depth of filter material --11-------------Total length ------Z— -0------------------•------ <br />Seepage Pit: Distance to nearest well_--------------------- Distance from foundation ________............ Distance to nearest lot line __-___--__-______ <br />❑ Number of pits ---------------------- Lining material ----------------------- Size: Diameter ----------------------- Depth ---------- .__________--_-___--_ <br />Cesspool: Distance from nearest well ;,_;__.__Distance from foundation :_-____-_---_.____.Lining material -------------------------------------- <br />171 Size: Diameter--------------------------------------Depth-------------------------------------------------Liquid Capacity-.------------------- ------gals. <br />Privy: Distance from nearest well ------------- _----------------------------------- Distance from nearest building _____-_____-______-_____________-_____- <br />❑ Distance to nearest lot-line----------------------•------------------------------------------------------------------------------------------- ------------------------- <br />Remodeling and/or repairing (describe):--• ---------------------------- ----------------------------------------------------------------- --------------------------------------------------------- <br />---------------------------------------------------------- <br />-----------------------------•-----------------•--------------------=-- --------------------•-•-----•------------------------------------------------------ --- ---------------------------------------------------------- <br />---------------------------•------------------------•------------------------------------------- -•--•-------------•------------------------------------------------------ == ' -------•---•-------------------------------- <br />I hereby certify that I have prepared this application and that the work will be done in accordanc.W with San Joaquin County <br />ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br />_1L . <br />(Signed)--.... Y ----------------- '' = ---------------------------------------------------------------------(Owner and/or Contractor) <br />By: ----------------------------------------------------------------------------------------------- ....... --------------------------- (Title)--------------------------------------------------- ------------ <br />(Plot plan, showing size of lot, location of system in relation to wells,, buildings, etc., can be placed on reverse side). <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY----------------------------- (I ---------------------------------------------------- DATE -------•---�, a'� <br />- --------------------------------- <br />REVIEWED <br />NG PERMIT ISSUED =------------------------- DATE------------- ---- -------------------------------------- <br />BUILD <br />-------------------=----••------------------------------- DATE------------------------------ ---------- -------•----------- <br />Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------- ---------------------------------- <br />-------------------------------------------------------------------------------- -----•--------------------------------------------------- --------•-•---------•----------------------------------------------------------- <br />---------------------=-------------------------------------------------------------------------------------------------------------------- -------------- <br />5 <br />FINAL INSPECTION BY: ��I/�'� Date_'. ---------- A% <br />`---------------------------•-------------- <br />SAN JOAQUIN LOCAL HEALTH'DISTRICT <br />130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Street <br />Stockton, California Lodi, California Manteca, California Tracy, California <br />ES -9-2M . Revisea 1.57 F.P.CO. <br />