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APPLICATION FOR SANITATION PERMIT Permit No. _/ll----- (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 LOCATIO ____'yg Owner's Name----� o"----6410CItAX1.4----- ---------------------------------------------------------------------------------------------- Phone------------------------------------ ----------------------------------------------------------------------- Address-----------/Ur0---- Contractor's Name------ ------ ----------------------•--- Phone --------—- . Installation will serve: Residence ® Apar ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___1___ \Number of bedrooms _:- __ Number of baths ---/--- Lot size Water Supply: Public system ❑ Community system q Private ❑ Depth to Water Table _.1Kaft. ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R Hardpan ❑ Previous Application Made: Yes ❑ No 9 New Construction: Yes 4 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---/21oft_ ,C_Distance from foundation----/Q.........Material------ No. of compartments_-- ------------Size___ ..X_d—?'�_?_____Liquid depth__-1;/-------------------Capacity--2-VO Disposal Field: Distance from nearest well>A4r^,C_ Distance from foundation___ ---------Distance to nearest lot line__ ______ 91 Number of lines---------------._�L___------_ Length of each line-----Z$--'__.__-______-.Width of trench___''.__-____ -------------- Type of filter material___ _ _ _____Depth of filter material--- .JT--_"----------Total length---- ,f"6_________________________ See it: Distance to nearest well___ —------Distance from foundation____-7,J-"......Distance to nearest lot line----- -----___ ® Number of pits-----______------Lining material_-___--17c��_Size: Diameter___��-__-____Depth....S'----------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------_:___.Lining material_____________________-____-___-__ ❑ Size: Diameter------------------------- `-----------Depth---------------------------=------------------------Liquid Capacity------------------- = gals. Privy: Distance from nearest well ___--------------------------------------------Distance from nearest building------------------------------- ----_____._ ❑ Distance to nearest lot line ---------------- ------------------------------------•------------------------------------------------------- Remodelingand/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 nd regulations of the San Joa in Local Health District. { e _ (Signed) - - . ------. - - - (Owner and/or c;ontractor" }" q By:--------------------- ---&-------- ------------------ (Title)---vim G -�---------------------- -- - - ------ ------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ti FOR DEPARTMENT USE ONLY .// APPLICATION ACCEPTED BY-- ------- ------ DATE----- l - i ---------------------------- 1 REVIEWED BY--------------------------------- - --------------------------- ------ DATE - - BUILDING PERMIT ISSUED----------------------------------- ---------------- -----------------=----------------------------- DATE------ ------------------ Alterations and/or recommendations----------- -------'---------- ----------------------------------------------------------------------------------------------------------------------------- ----------------_---------------------------------- -----------------------------------•--------------------------•------------------------•------------------------------------------------------------------------------------------------------••---------------------------•--------------------------- -------------m----------- --------•------ ----•----------------------•-------------- ----••------------ ---------------------------•-- ------------------------------------- •---------------_._-----_.- ----------------------------------------- ---------------------:---------------------------------------------------------- ------------------------------------------------------------------------------------------------- -------------------------------- -----------------------------------•-----------------------•---- ---------•----------------•-------- -------•--------------------------------------------------------- ---------- ---------------------------------- FINAL INSPECTIONBY:---0vt -s= Date-.----- .--J--�-------------------------------------------- a 1i� ---------------------------------- 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.