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APPLICATION FOR SANITATION PERMIT Permit No. __!_7____j______ 4_,;V1 0 (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. Th is application is made,in compliance.with County Ordinance No. 549. +J 0S I^ 0410--(7 lVBMADDRESS AND OCATION_____[/_ _---- 4. --------- ------------------ . Phone------------------------------------ Owner's Name____,4,5 --------------------------------------------- "� --------------------------------- - - - Contractor's Name —------------------------------ --------------------------- ----------------------------------------------------------- Phone---------•------------------------- Installation will serve: Residence X Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1----- Number of bedrooms -1----- Number of baths __/____ Lot size ---%TPA-----/._1{O_---------------------------- i Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table ________ ft. i Character of soil to a depth of 3 feet: Sand;9 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No,�@ New Construction: Yes ❑ No EkI PHA/VA: Yes ❑ No ❑ TYPE'OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__JF74Q__i_---Distance from fopndation------Y----------Material---- _-----_ ______________•__-_.________-- No. of compartments------2----------------Size--f4_-Z-t___S-----:---Liquid depth-----Y------------------Capacity._ '_&o------ - Disposal Field: Distance from nearest well._$7f'D.._____Distance from foundation---7--______-_.Distance to nearest lot line� --- ____ _ O Number of lines--------/_----- ----- ---- Length of each line----�_b------------------Width of trench.----'y- I----_-------------- Type of filter materia _:___J Depth of filter material__, _��_____.__Tofial length._. _Q_'____________________________ Seepage Pit: Distance to nearest wei_X_PP---------Distance frQm fun ation------7-----------Distance to nearest lot line__ _____._ Number of pits------/--------------Lining materio150W..Size: Diameter--.3-l"...` __.__-_.Depth_-Z.,---__________________- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.------------------------------------- 0 Size: Diameter------ ---------- --- ---------------Depth------------------------------------------------ --Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building----- ----------------------__----.-___-_. ❑ Distance to nearest lot line-- ------------------------------------------------------------------ ------------------------------ -------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- ---------------------•-------•---------- � '`-!`= •----d�•r------ !+'�?- T_✓-------� �--------------------•-••------------------------------------ ------------------------------------------------------------------- ------- _.. ------------------------------- ---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and regulations of the San Joaquin Local Health District. (Signed} ------------------------ --------------------------------------------------------------------(Owner and/or Contractor) 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--$-7-0__--0--------------------------------------- REVIEWED ------------------------- -- - - REVIEWEDBY------------------------------------------------------------------------------ - --------------------------- DATE---------------------------- BUILDING PERMIT ISSUED----_---------------- ------------ ------- DATE-------------___----__ Alterations and/or recommendations:__®�. -- ----•- -------------------------•----------•--------------------------------------------•------- •---------------------- - - - - - - -------------------------------------------- ------------------- ----------- _- p -------------------------------------------------- -------------------- ------------------------ ------------ ------------------ ----•-- --------------------------•--------------------------------------------------------•----------------------------------•--•--------------------------------------------------------------------•--- FINAL INSPECTION BY:.- --------------------- Date e.- ' -------- --------------- SAN-30,AQUIN 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 F.P.CO.