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• ` 1 ; fPermit No. . . APPLICATION FOR SANITATION PERMIT * 1� (Complete in Duplicate) Date Issued ____________ I1c$tion is hereby shade to the San Juin Local Hea +s ri�tor a pe m1 truc't a sty the work.herein descri d. Th is application is made in compliance with County Ordinaance No: 549. 9 / JOB ADDRESS AND LOCATION.L,____ -----------'7--------- Owner's Name Sr`�-----�-�-- ---- �-------------- ------ - Phone r _ ----- - ---------------------- Address /�� --------- �,, Phone ' Contractor's"Name--------- - - --/�---' ^s = u- "�-- -- Installation will serve: Residence g?'Apartment House ❑ Commercial ❑ Trailer Court ❑ ❑ Other Motel ff � ❑ l 3 Number of living units: _/._ Number of bedrooms j9__ Number of-baths _/-_- Lot size ------- - - Water Supply: Public system ❑ Community system IvIlprivate ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy'Loam ❑—Clay,Loam ❑ Clay ❑ Adobe[T]�iardpan E] Previous Application Made: Yes ❑ No New Construction: Yes E--1 o ❑ �FHA/VA. Yes g�- No ❑ F TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public se er is available within 200 feet.} Septic Ta k: Distance from nearest well)* Distance from foundation-_!_o----------.Matefial��-_____ No. of compartments-- --�r__-_-------- --Size__ O_ s �.------.Liquid depth---- //r Capacity---- -------- /�""v i ( Disposal field: Distance from nearest well�ADistance from foundation__ L�_�__---_-.Distance to nearest lot line�_____S f r Number of lines_------_�------------=-=- Length of each line___�3t7__-_�fcaaWidtk of trench._._-_ot'�------------------ �$_.r----.-Total length---------/`5�-------------------- Type of filter material-�_4 Depth of filter materia_-- ___ Seepag10, e it: Distance to nearest well Distance m undation---/0_---.__..D' ance to nearest lot lin ------------------ Number `___.___ � Number of pits_..._---.-_ --Lining material__ _ - ---:Size: Diameter----- ia° Depth w?' I Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------.._______-._--__-. p� { ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid CapacitY----------------------------gals. M I Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-.---------------------------------------- Distance ---------_---------------------- ------ Distanceto nearest lot line----------------------------------------------- ------------------------ ----------------------------- ----------------------------------- Remodeling and/or repairing (describe):---------------------- ----------------------------------------------------- --------------------------------------------------------- - --------------------- ------;._------- ------- _--- ------------ L------------------ ------------------ --------------------------------------------------------------- ------------------------------------------------------------ - ------- ---- ---------------•------------- I hereby ify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a e laws, And rules regulations of the San Joaquin Local Health District. ; - ---- --------------- __ (Owner and/or Contractor) (Signed) -•---- ---- ------------------------ By:--------------------------------------------- -- -- - ---------------{Title)- ---- -- - --------------------------- -------------------- (Plot plan, showing size of lot, location of system in relation wells, buildings, etc., can be placed on reverse side}. FOR DEPARTMENT USE ONLY K APPLICATION ACCEPTED BY__, -•- _ DATE�----------------------------------------------------- --------------------------------------------------------------------------------------- REVIEWEDBY ----------------- = ----------------------- ---------- ------------------------------------------------------------------- DATE_? BUILDING PERMIT ISSUED----------- -------------- ---------- ------------------------- DATE---- j Alterations nd ``orec mmend`ations: r --- f r1I ' ----------------------------------------------------------------------•---------_-------•------------------- 2$4------ ------ �� -.7s1" ----------------- = e {----------------- - 20 _ = = 1 ------- ---- ------- ------------------ ------ --------------------- -------------------- ---------- --•--SYS �r-------- -------- -. ---[------------------------------------------ ---------------------- . --------------------- FINAL INSPECTION BY:------------�7n;.a --------------------- -- / Date-------T '-5 ------ -------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "G" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Ravised 1-57 F.P.CO.