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(APPLICATION FOR SANITATION PERMIT Permit No----- -------------------- (Complete in Duplicate) 1� rr/ / 1 Date Issued -- - - -_-b-_-- Application is hereby made to the San Joaquin Local Health District for a permit to ruct and install the work herein described. This application is made in compliance with County Ord'nanc No. 549.. r �j -��--�---. � - -- JOB ADDRESS AND LOCATION---- R7 -------------- ---------------------------------------- '/y }A r Owner's Name U4� -L4_ Phone Address----------- • - --- - ---------- ------ --------------------------- ------------------- ......-•----------------------------------------------------------- Contractor's Name----------------- ------ --------------- Phone---•--------------•------•--------- - -- - ------ Installation will serve: Residence gq--A+partment House ❑' Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: -1__-_ Number of bedrooms,.---/- Number of baths __ __ Lot size ------------------------ Water Supply: Public system �mmunity system El Private ❑ Depth to Water Table ft. .I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No V New Construction: Yes ❑ No jR 'FHA/VA: Yes ❑ No 21 r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) r - Septic Ta : Distance from nearest welt_ ice'/�Uistancerf om foundation----- __Ie�------Materi -------- No. of compartments__ __ _/�---------------Size__�__�__�X_e/V---__Liquid dePth__y� ------_-Capacity_____ __ . Disposal Field: Distance from nearest well,_/ ?P_D stance from foundation-----1(f'......Distance to nearest lotI• _-_-__ • Number of lines------------ ------------ enth of each line--------�i�_/ Width of trench.____i�✓� Type of filter material__ __.___ epth of filter material------�_l!L______----Total length----------ire------------------------ Seepage Pit: Distance to nearest well----------------------- from foundation--------------------Distance to nearest lot line--------__-_--__ ❑ Number of pits----------------- Lining material-----------------------Size: Diameter-----------------------Depth-.-.----------------------------- Cesspool: ------------------------ Cesspool: Distance from nearest well_________________Distance from foundation_-------------------Lining material----------- -_._---.-------------_ ❑ -- .�. - ' Liquid Capacity----------------------------gals. Size:.Diameter------ ------------------ ----- ---Depth------------------------------------- ------- } ' Distance from nearest build in Privy: Distance from nearest well----- - ---------------------------------- --- g----------------------------- - ❑ +Distance to nearest lot line-------------------------------- ---------� ----------------�G��--�;--------------------------------------------------------- -------- -- ---- Remodeli 2460 71�'t ,ng an or repairing (describe):--- - ------••-•--------- �� -- ----------- "vim � ------- -4� ----------------------- .- - ._- I --- ---- ----- --� ---- ---------------------------------------------------------------------------------------------------------------- --------- 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 4anregulations of he San Joaquin Local Health District. 7 t Contractor) Signed (�r C or) t �minrelation ----- (Title) (Plot plan, showing size of lot, location of s to wells, buildings, etc., can be placed on reverse side). r ` FOR DEPARTMENT USE ONLY ef APPLICATION ACCEPTED BY- -------------- ---- DATE T-- -- --------------- REVIEWED BY ----------------------- DATE---- .- - ------- ------------------------------ - ----- BUILDING PERMIT ISSUED------------------- --- - ---- - ------------------ DATE Alterationsand/or recommendations--------------------------- - -------------------------------------------------------------=----•---------------------•-- ----•--•--------------------•------- ---------------------- - ----------------- ------------------------------------------------ - - ------------------------------------- I ----•----------------------------------=------ ----------------- ------------- 14 € -----------•---------- ' ------------------ -----------------------------•---------------------------------- FINAL INSPECTION BY:--- 2 e Date ` . _ - --- fi-------•--------- l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street : .$14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1.57 RP.CO.