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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ---- Application ___ A lication is hereby made to the San Joaquin Local Health District for permit to cons ruct and 'nstall the work h in d cribed. PP Y q � This application is made in complia with County Ordinance No. 549 �� o-� �j,� JOB ADDRESS AN LOCATION----<.; - ---------------- - - -- ---- _ } Owner's Name------- _ ..... ----�L__S---- - ---r------- 7`2---A-�---- ------ ------------ �. `` + Phone_-- �_�] Address...-••-•----•--......--1•�-----W- �- ._•---�- � --------------- . a"v..1------------------------------------------------------------------ ----- Contractor's Name-----{ —� �------------------------ ----------------------------------------------------- Phone---------------------------------- Installation will serve: 1 Residence hd' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ E Number of living units: __V___ Number of bedrooms _- Number f baths __�____ Lot size ---�'N - R --------------------------- Water Supply: Public system E] Communi-}y system El Private j Depth to Water Table 4177f. r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes E] No R New Construction: Yes:[I No Q. ; FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cess ool permitted if public se_wer is available w.Ir%0200 feet.) Septic ank: Disfance from nearest weh__.Sb_ Distaf 0 aton______L!_II ---.Material------ _ ______ �______. - Noof compartments.. _th ____.. ___ .-_ Size__ � Li d de -__- . Ca acitY. __ Dispos " Field: Distance from nearest well...u7D-----.Distance from fouhdation___---+�_�?-------.Distance to nearest Ion line_________________ Number of lines_____________ _ -__ Length of each line-----_ �_-__ -_ -__-_-_.Width of trench----2.__ ---------------------- __ o Type of filter material_____ p h g T _____De th of filter niateri�_. -,__-________.Total length--- �- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__.___________.__ i ❑ Number of pits.---------------------Lining material-----------------------Size: Diameter-----------------------.Depth----------------------•---------- f� 3 F - 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__________________---_-______-.---.-_-__. ED Disfance to nearest lot line -------------------------------------------=-------------'- --------------------------------------------------------------------- ea ; --m Rodeling and/or repairing (describe):_------------------------------------------------•--------------------- F� I y- _______________�______-_ - r { A 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 ru[ d re ulations of the San Joaquin Local Health District. (Signed)----------- y f - - - - (Plot plan, showing size of a , location o system in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY �} APPLICATION ACCEPTED BY----------------- ------- a-------- ------------------ DATE _ 14i ------------------- REVIEWED BY----------------------------------------=--- ---- ---------------- -- ------ DATE BUILDING PERMIT ISSUED - --- -- -- ------------------ - DATE - -------- Alterations and/or recommendations------ ------ ---- ------ - ------------------------------------------------ ---------•---------------------------------------------------------------- •----------------------------------------------------------------------------------------------------•--------------------------------------------------------------------•------ -•-------------------------------------- -----------------------------------------------------177q -------- ------ ---- --- - -- , -- ------------------------------------------------------------------------------------ - ------------------------------------=--------- ----------------- --------- ---------- ----- --------------------------------------------------------------- ----- I n FINAL INSPECTION_BY-� -------- Date-- L- G} f ---------- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Mantaca, California Tracy, California ES-9-21x1 Revised 1.57 F.P.CO-