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APPLICATION FOR SANITATION PERMIT Permit No. ..� --------------- (Complete -— _ - (Complete in Duplicate) (o/ Date Issued ____.__'.2. � D v, App kation is hereby made to the San Joaquin Local Health District for a permit to construct and install teed. This application is made in compliance with County Ordinance No. 549. > JOB ADDRESS ANS LOC.ATION/.. f ------L Owner's Name-- _�__ --- -----=- - ---- - _ - � Phone Address-- ---- ---_.;_. -i --- --- ------------------------ -8l l --- ----------- -----�'�---------------�-- Contractor's Name___ ..__----- _ _ .�cC __ _ .yF _ _ ..cC-�.--�--- Phone. _tz�-- _�_.,/..�' -! Installation will serve: Reside c Apart ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms _.r___ Number of baths _/___ Lot site Water Supply: Public system .] 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 2] Hardpan ❑ Previous Application Made: +s ❑ No U ``New Construction: Yes Z No ❑ FHA/ : Yes E] No IN TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesslDool permitted if public sewer is available within 200 feet.)` Septic Tank: Distance f'om nearest well-_-____-_--____Distance from foundation---------- 1 171 NO. of co partments--------- --------------Size-------------------------------Liquid depths.------------------------Capacity----------------------- Disposal Field: Distance f om nearest well-----------------Distance from foundation__-____..__F--____).Distance to nearest lot line_________________ � ❑ Number o lines-----------------------------------Length of each line----- -------------------- -Width of trench - Q Type of fi er material__________________ __ __Dept filter material--- ____.__Total length---.___.._________.____------------------- , 0 _. _--- Seepage Pit: Distance to nearest we -------Di ante fpm f ndation _ istance to nearest lot line-- N Number of pits------- -------i- ma erial_Zez ___Size: Diam ter_ `Depth----�,` '"- --_-- ---------- Cesspool: Distance from nearest w'II____--;_--__.__Distance frorp foundation_-________________Lining material_____.___._.-____-_____.._____-__ ------De th--------------------------------------------------- Li uid Capacity-.❑ Size: Diameter------------------ -----: P q P Y gals. Privy: Distance from nearest w II_____#_____.____________________________,p;stance from -•----•- - - --- -- ----- --- --- ❑ Distance to nearest lot line_ ..___.._ ___ --- ---------- Remodeling and/or repairing (describe):_] A� a�- ------• •----- --------------------- ____/------------•--- --------------------------•----------------------------------------------------- ------------------------------_--- --- ------------------------------------------------------------------------------- ----- ----- ---------•--------------------------------- I hereby certify that I have prepared this i pplication and that the work will be d $ in ccordance with San Joaquin County ordinances, State laws, nd rules and regulatiors of the San Joaquin Local Health Distr t. (Signed)_ l = - - -- - - --------------------------------------- ------1-------- ----_O and/or Contractor) B = f - --------------------(Title)-`, -------------------------- (Plot pl�n, wing s' lot, location of system in relation to wells, buildings, etc., can be placed on r ver sale). FOR DEPARTMENTS SEPNLY APPLICATION ACCEMD BY�7- . _ _ `. I A - ------------------ D TE_ REVIEWED BY r I _ _ w__ :-.: -- ---- 4t --- - -- - � - ---- ---------- --------------- BUILDING PERMIT ISSUED---- �.-l---------------------------------------------_ DATE--- " Iteraji ns and/or r end ins. .. 1 i - G .'r .Vit_!-c� -_� _ :`I_f ✓'t!k =��-' ` � �" r , -; - - _f--__ _ 3 ----------------------------------------------- i • - •_ �. ---------------- -------------------------------------------------------------------------- ------------------------------------------------------- FINAL INSPECTION BY:-_ ---- --- ------ Date 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 . Revisaa 1.57 F.P.CO.