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* Permit No. 2- APPLICATION FOR SANITATION PERMIT / (Complete in Duplicate) Date Issued Application is hereby made to the San Joaqbin Local Health District for a perm to co truc# d install wo��++'k herei d scrri�ed This applicatiori is mad�n compliance with County Ordinance No. 549. � � A- AeA JOB ADDRESS AND LO TION -�'---- - --- f-- -----7-n-4 •-C1`'`-'`---•- �p_,/ -- ----._- T` -:.- Owner's Name-------------- r '� - 1'-- - Ph ne -------------------------------- �r Address-------------------------- ....... -- --- ---- ------- --1 f - Z---- ------ 1 Contractor's Name .' =' - --•------------------------------------------------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ --- Number of bedrooms _umber of aths _!-___ Lot size __ __ _.__- � � - „ Commuriit system Private De th to Water Table _ Water Supply: Public system ❑ y y ❑ Character of soil to a depth of 3 feet: %An%Gravel ❑ Sandy Lo;�<o lay Loam ❑ Clay ❑ .Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No eptic tank or'cesspool permitted if public sewer is available within 200 feet.) r / . r Septic ank: Distance from nearest well"7 J7istan e from foun n__� -k L.►slulate�aI---- J __4_----_- �/ No. of compartments_-___' c'.__.____. _ Size_ ., .-/ -_ _. _:___Liquid depth____ Capacity---- _ , � -- ---------- ..�r Disposa�ield: Distance from nearest well-!_2:) )istance from foundation''-_'''Distance to nearest lot line-----{.- ' r, Number of lines_____-_ __ Length of each line_______�/___________________Wld#h of trench__. ___ " Type of filter material ___ _.___ Depth of filter—material___.f ._____Total length_____________ _; __________.__..._ + Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line---------------- ? ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------.Dept h----- ---- --------------------- j Cesspool: Distance from nearest well-----------------Disf nce from foundation--- ----------------Lining material_._-_____-------.----._-__------_ ❑ Size: Diameter---------------------------- ---- ----Depth---------------------------------------------------Liquid Capacity-_-------------------------gal. Privy: Distance from nearest well----------------------------------..-------------Distance from nearest buildinga ❑ Distance to nearest lotline--------------------------------- --- ------------------------------------------------•------- -------------------------- Remodelingand/or repairing (describel:--------N------------------------------------•••----------------------------------------------•---------------------------------------•-----_-------- --•---•------------------------•------------------------------------------------- ----------------------------------------------------------------•----_-----------------------------•---------•- •------------------------ -----------------------_--------------------------------------------- ----- - ----------•--------------•------------------------------•----•------- -----•----------------•-•-----------------------•-•--•-------------•--• --------•---------------•---------------•---•-----------------•------------- 1 ----------------- ---------------------------------•-----------------------••-•----------------------------------------------------------•-----------------------------------•----•----•-- -------- - { I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Couni ordinances, S ate laws, and rules and regulations of the San Joaquin Local Health District. % I a P (Signed-----=- --- ' `• "' e�l; __ � -esr (Owner and/or Cantractorl Br-----------------------------------------------------------:-----------------------------_-----------------------------------------.( itle) _---•--------------------------------------------- ---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). OR DEPARTMEIVr'r-OSE ONL = — . APPLICATION ACCEPTED BY----- == - - -- ---•---- DATE --------------- -- - ---------------- REVIEWEDBY------------------------- -------------------•- -- --------------- -----------------------------------------•-----------� DATE-•---------------------------------------------------------- BUILDING --------------••---•---------...---•-•-BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------------- -----•--- DATE------------------------------------------- Alterationsand/or recommendations------------------- --------------------------------------------•------------------------------•-•-----...........................-•---------------------._.. ---------------------•-------------------------------------------•-------------------- -------------------------------•-------------------------------------------------------- -------------..---------•--- ------•-------- --------------------------------------- ------•-------------•--.--•---- --------------------------------------------------------------- -------------------------•--•---------------------------•------------------------•--- ---------------------------------------------------------------------•----------------------------•------------------------------------ ----------- ------ -------------------- FINAL INSPECTION BY---------- -- -- -•-.-- Date__ ----�1 0 ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT r, 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.