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r 1} APPLICATION FOR SANITATION PERMIT Permit Nor.,.&__G_._f,7------- onr (Complete in Duplicate) z S Date Issued Application is heteby made to the (an Joaquin Local Health District for a permit to construct and install the work herein described. Thrs application is -made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION ------ Owner's Name-------- -- ------------------------------------------- -------------------------------------------------------------- ---------------------------- Phone_Address------------ -F�_ "__.. = m Contractor's Name-- -- = i------0_r_17_Z== ' ---------------------- Phone------- ---------------- ---------- Installation will server Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I____ Number of bedrooms a__ Number of baths --- Lot size Water Supply: Public system_[ Community system ❑ Private ❑ Depth to Water Table _ ft. Character of soil to a depth' of -3 .feet:, Sand. ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe 19/ Hardpan ❑ Previous Application Made: Yes E] No [� New Construction: Yes IRI No E]FHA/VA: Yes Y No E] TYPE OF INSTALLATION .AND SPECIFICATIONS: (No septic tan or'cessFmol p mitt I ublic sewer is available within 200 feet.) �Q ...... ' S ptic T nl �I`Ur ce om earesr well-__FQ�Distance from foundation______,'�___Maerial___�__ ____. --- No. __ No.'of compartment -------2�........ ....... Size.0XZ__Y�j---------Liquid d pfh------ --.-.-------- -Capacity----- ---------� Disposal Field:iWer am nearest well ---- U�_ Distance from foundation --Distance to nearest lot line____'S ------ ___VVV jEf 1� ulines------- ___ Length of each line_________ _LQ----q---------Width of trench_____ _________________________ w 1 (• Type of filter material__Depth of filter material ___--g'_ -------- Total length _____--:�F-------------------------- Se rt: Distance to nearest well_____________Distance from foundation ___......-______._..Distance to nearest lot line _____.____.____._ Number;of pits -------------- _------- Lining material ----------------------- Size: Diameter ----------------------- Depth -_______________-___---___._____ Cesspool: Distance from nearest well ----------------- Distance from foundation___. ---------------- Lining material ------------------------------------- • ❑ Size: Diameter------------------------------------Depth---------:-----------------------------------------Liquid Capacity ----------------------------9 S. Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building _________________________-__--__________- ❑ f x Distance to nearest lot line ----------------- ----------------------------- ---------------------- --------------- - ; Remodeling and/or repairing (describe)--------------------------------------------------------------------•------------------------------------- - c ----------- �� - ---= - -- -------- -- _-----__ --•_---------- -------------------------------------- __ _ yj -- 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 rules and r ulations of the San Joaquin Local Health District. (Signed) ------------------------------------------------------(Owner and/or Contractorl By:--------------------------------------------------------------------------------------------------------------------------------(Title)------------------------- (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------------------ ------------ REVIEWED BY DATE ------------------- BUILDING PERMIT ISSUED ------------------------------ ------------------ -------------- DATE----------------- -- -------- ----------- Alterations and/or recommendations:-------------------------- -- -------------------------------------------------------------•---------•-----•-------------------•--------" ----------------------------------------------•----- ------------------...--------------------------------------------------- ------------------ ------------------------------------------------------- --- ef--------- --------- ------ ------------ I--------------------------------------------------------------------------------------------- ------------------ ------ - ------ - -----------------•--------------------------------------------------------------------------------------- FINAL INSPECTION BY:__ 1.- Date - r .f ""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 -9-2 M,, Revisea 1-57 F.P,CO.