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APPLICATION FOR SANITATION PERMIT Permit No. _._2//IR.4�-___ \� ! f (Complete in Duplicate) ( Date Issued _____ 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. JOB ADDRESS AND LOC TION-_3-_r3__/ -___ Q. Owner's Name_____ i-- - ------------------- Phone Address____-____J_3__�(0__� `�J/`�) __ ___------------------------------------ ------------ Contractor's _ _ _______________•--_-_-_-- Contractor's Name _------°�---- _ --- --------------------------------------------------------- Phone---------�-----7 Installation will serve: Residence (4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---1--- Number of bedrooms __-2, Number of baths ___L___ Lot size ----4---___oklc__A�- Water Supply: Public system ❑ Community system ❑ Private W Depth to Water Table _#Cft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [4 Hardpan ❑ Previous Application Made: Yes [—] No � New Construction: Yes E] No E] 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---%__v------Distance from foundation__r0__ ______-___.Material--- __� F+a`9- �,. No. of compartments____Z.__-__-__-__--__Size____-: x _X_ -----_---Liquid depth----41__'_-__--_____-__Capacity__.rgVj--{__ Disposal Field: Distance from nearest well_A5� ____Distance from founda/tion.A4!_ Distance to nearest lot line__!>__�___.__. +I Number of lines-----.____-____/______ of each line_�;3_C?_f_-�_4'_______-Width of trench____ Z ----------------------- Length J Type of filter material__a--2,l-'_______--Depth of filter material__--1_T__ ---------Total length--------� ---------------------------- n► S Pit: Distance to nearest well -_,,S=c2�----------Distance from foundation__' O............Distance to nearest lot line--s�.- ®`' Number of pits--------I___________Lining materiaL_____1 f Q-C_f(_-Size: Diameter__'X 4----------Dept h___-_-_4---`________ ____._ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_________ El Size: Diameter------------------------ ------------Depth---------------------------------------------------Liquid Capacity-.-------------------------- Privy: Distance from nearest well _________________________-_______-------------Distance 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 and egulations of the San Joa uin Local Health District. (Signed)-------------------�_ (Owner and/or Contractor By:----------------------------------------- -- __�---------------- ---------- Title ) Ga✓ (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 APPLICATION ACCEPTED BY-_____ ___________;� - DATE___-__________-__-- ------- -- -- -- -- REV ------------------------- ------------------------------ BUILDING PERMIT ISSUED — - DATE ,> 'v ----------------------- IEWED BY -------------------------------------------------------------------. DATE-- - Alterations and or J- r recommendations:- -----------h _ - ----- - -- -- -- - - --� ------- - --------------------------------------------------- ---- --------------------------- ------------------------------------------------------------------- ------------------------------------------------------------------------------------------------ ----------------- ------------------------ ---------------------------------------------------------------- FINAL INSPECTION BY:.f�. --�- ,-/,, � ------------------------- Date--- �J X------------------------------------- N 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 F.P.CO.