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/k O n APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ~ Date issued __f7___/e- F, 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 LOCATION____ �. +' �7 I f Owner's Name ffl_Z-oC-`- r Phone------------------------------------ i ------------------ fiContractor's Name = ------------------------------------------ -- Phone-J�711a` Installation will serve: Residence ®apartment House ElCommercial E] ou Trailer Crt ❑ Motel [] Other ❑ ,� - �.�. 'X/ ----,Cj Number of living units: __ Number of bed oms _ ____ Number of baths __.� Lotsize �__ t k Water Supply: Public system Community system ❑ Private,❑ -Depth to Water Table,?_ ft. ► P Character of soil to a depth of 3 feet: San d ❑ ;ravel ❑ Sandy Loam Delay Loa j❑ Clay ❑ Adobe gil—Hardpan ❑ Previous Application Made: Yes ❑ No [a New Construction: Yes ❑ No Rj-""FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) + -------------------Material----------------------------------------------- If --------------------------- 1 Dis ance from $ is nk: Not of compartmentst well ---Distance from foundationLi uid depth) - q P. -----------------Capacity---------------------- Disposal Id: Distance from nearest + ell__/ �f4�,-_Distance!from fcundation___�_��_�-__.Distance to nearest lot line____-�f__ Number of lines__________-/--------_________ _Le, gth of each line------«_�_--ir--.Width of french-__-_y,l�- � Type of filter material IiW st th offilter material______ _--------Total length___._____ sS------------------- �_ Seepage. Pit: Distance to nearest well+- - ` f i _Distanc om f Wu ion D'------.Distance to nearest lot line------S___-._ Number of pits._.__/------f------Lining material_ -_Size: Diameter_--- .3_ _� Depth-------.2-S----------------- \ Cesspool: Distance from nearest well-----------------Distance from foundation-_.-----------------Lin ing material------------------------------------- (�� ❑ Size: Diameter--------------- --------:---- --------Depth--------------------:------------------------------Liquid Liquid -------------------- ----gals. `1l Privy: Distance from nearest well_________________________._____-___.-------(Distance from nearest building-----------_____-_"__________________--._. ❑ Distance to nearest lot line----------------------------------------------�=------------•------------ ------------------------------------ --------- I Remodeling and/or repairing (describe):------ r - UI.-, it t + ------------------------------------------------------�j---------------------- . I 7 --------- --- - ----------------------- ��----r---------.--------•---------------------------------------•----•---- ----------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, ate)laws, and rules and regulationsrof.th`e-San-JoaquimLocal-Health-Districts ' (Signed '� -- ------- wrier and/or Contractor ) �._ ---- ------------------------ t r BY= --------------------------------------(Title)--------------------"-------------------------------------------- (Plot plan, showing size of Ivt, location of system i�noelation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------- ----------------------- -------------------------------------------- DATE------------- --------------------------- REVIEWED BY----------------------------------------=---- ------ -- -- ---- -------------------- ----------------- DATE--------4_r BUILDING PERMIT ISSUED---------------------------------- ----- --------- - ------------------------------------- DATE--------- Alterationsand/or recommendations---------------- ------------- --------------------------------------------------------------------------• ----------------------•------------- ---------------------- ------------------------------------------------------- --------------------------------------------------------------------_•---------------------------------•------.--------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -----•---------------------------------------------•----------------------------------------------------- ----•--------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY----------- - ---- ---------------- Date----- - - ---o GG.-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh 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.00.