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APPLICATION FOR SANITATION PERMIT Permit No. ._l '__ �- (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. 549. 1 r r fl 1,- j , JOB ADDRESS AND OCATION----- .--,--A_qy__j"J---------------'-'- -------------------------------------------------------- Owner's Name----------- -- �---F__ C it ' & ----------------- - -------------------------------------------- Phone-- _1-P--- Address---------------------------------------------------� � L '� ..�:--------------------------------------------------------------------- Contractor's Name------------------------------------()_7.�4 ------- -------- - ------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence VAparfinent House-[] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number.of bedrooms _ _ ___._ Number of baths _�__ Lot size _______/_6E4- ------------------------- _ __ 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 ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ! New Construction: Yes ❑ No n/f FHA/VA: Yes ❑ No ❑ { TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) l Septic Tank: Distance from nearest well___. --------Distance from foundation--____._.'____----.Material_________________________________________________ ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--- ---------------------Capacity-------------- Disposal ield: Distance from nearest well x _______-Distance from foundation___________________Distance to nearest lot line- ---------------- Number i oe__�_________-. Number of lines-------/_::___'____' _____=:Length of each line________ L, __________.Width of french___-----I'-"_"_______________" Type of filter material_ __ `► -.______Depth of filter.mater'iahL'€_ - ---__.----Total length______;_��___________________"------ Seepage Pit: Distance to nearest well----------------------Distance from foundation___________........Distance to nearest lot cine_________________ ❑ Number of pits----------------------Lining material--------------.--------Size: Diameter------------------------Depth------.-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation --------------- material__.____---__-----_-__--______________ ❑ Size: Diameter------------------------ -------------Depth-------:-------------------7 -------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well____'_______________ __________------------------Distance from nearest building----------.------------------------------- ❑ Distance to nearest lot Iine------------------------------------------------ -------? ---J ------'--------------------------------------------------------------- Remodeling and/or repairing (describe):-------------------------------------------------=-` J=---5-----------•"-------------------"-------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ ---- --------------------•----------------------------------------------------------------- ----------- -d -------------------------------------------------------------------=--------- --------------------------------------- -=----------- -•-------------------------------------------------•------------------------------------ ----------------------- -----------------------------•--------------------------------------------------------------•=------- ---------:-------------------_------------------•-------_------•---------------.-------------- 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 regulations of'the San Joaquin Local Health District. Si ned e jj ( g ---�---- - ------------------------------------------------- -- - - -----------------(Owner and/or Contractor) ------------- p 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-------04&14t4A ------------------ -----------------1-- ----------------- DATE---------- 7'f--- -_` REVIEWEDBY--------------------------------------------- -------------------------------=----------------------------------------------- DATE---------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------ - -- ------- Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------"-------•--- ------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------•----------------------------------------------------------------------------------------------------------------------------------•---------=---------------------------------------------- -----------------------------------•----------------------------------- --------------------------------------------------------------------------- --------------- -----------------------------=--------------•-------- ------------------------------ --------------------------- ------------------------------------ ------------------------------------------------------------------------------------------------------------------------------ ��FINAL INSPECTION BY: -------- --------- Date - ----- ---------------------------------- 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-7-2M Revisea 1.57 F.P CO. f-�