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APPLICATION FOR SANITATION PERMIT Permit No. .___I_..7- - Q [Complete in Duplicate) --"�.——7—c S 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 withCountyOrdina ce.No. 549. JOB 4ADDRESS AND LO TION - G S ---------'---------------••-,-c-.-,-,�------------------- Owners Name------------- ------------------ - Phone LJ____a-- ` - 7 l Address------------------------`------- -------------------------------------------------------------------------------------------------------------:------------L r 0--� --------------- Contractor's -- f* Name ---------------------`------------------------- ---------------------- --------------------- Phone --- Installation will serve: ` Residence [[/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _______ Number of bedrooms -------- Number of baths -------- Lot size -------------------------------------__--------------------- Water-Supply: _-_---_____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 ❑ -Aclobe ardpan ❑' Previous Application Made: Yes ❑ No ❑---New Construction: Yes [] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 t (No septic tank or'cesspool permitted if public sewer is.�available within 200 feet.) Septic Tank: Distance f eares6 e _�---------r_Distance from foundation___________________Material___-----_____-_-________---______------_____. ❑ No. of c6m --------- Size------------------------------Liquid depth------------------------=-Capacity-------- r Disposal F=ielcl: Distance-from nearest }"ell ______________.Distance from foundafon_ ` _ -._.1�'1Disfiance to nearest lot line-"""__________--. Number of lines---_-----/-----------------------Length of each.line^-=---_ -�-�------Width of trench----1��----------------- Type of filter material`_ -----Depth of filter material_---- -------;-----dotal length-------- --------------=-•--------- Y- r- ____.Size: Die Barest lot line_�"Q'�' Seepage Pit: Distance to nearest elle"�___Distance f om foundation_______, Di tante t n .�D . ©f Numbe of pits..____...______""___Linin material_ er___ __Depth_.__..._ _ R" Cesspool: Distance from nearest well------------------Distance from,foundation____".'___ _'__..Lining material--------._____-____._---_______--__. N4 -- - -=----.Depth--------------`-- -----------------------Liquid Capacity----------------------------gals. { ❑ Size: Diameter_______ ____________ __ _ _ y * i Privy: Distancefromnearest well________________________`---------------=-------Distance fromfnearest building------------.--________-___-------------- �^{ ❑ Distance'to nearest lot. line--------:--------------------------------------- --- ;-------------------------------------------------------------------- L - --- Remodeling and/or repairing '(describe):-•------ i ~------------------------ •----------•---- --A ---------- ,. .. -s ------ w i I hereby certify that I have prepared this'applicafion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rule and regulatio s.,of they San-Joaquin,Local Health District. _ - --- ------- ---------------- ----------------------------------------- ------(Owner and/or Contractor) (Signed) ,w {Title) its . B _ ---- --------------- (Plot plan, showing size of lot ocation of system in relation to wells, buildings, etc., can bye placed on reverse side).' OR DEPARTMENT 115E ONLY ` APPLICATION ACCEPTED BY ; -- ------------•----------- ------------------ DATE �/ REVIEWED BY------------------------------ ------ DATE--------------------------------------------•- ------------ -- ------------ _ BUILDINGPERMIT ISSUED-----------------=--—------ --------------------- - DATE-------------------------------------------------------------- Alterations and/or recommendations---------=---------;----- --------------------------------------k ------------------------------------- --•----•-------------------- .. t I __-_--___"__"" ______________________ �___._____--__._____-..______--____ _____ -----------------_----------------------------------------------------------------------------- - K - ----------•---""-- =te t . ,".'.". .--..Date--- ----- ------ ----------------------'------------------------- FINAL INSPECTION BY:-:-- 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 FY CO.