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APPLICATION FOR SANITATION PERMIT Permit No. _h... {Complete in Duplicate} Date issued This Permit Expires 1 Year From 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 with County Ordinance No. 549. JOB ADDRESS AND LOCATION--- -- -------------------------------------------- Owner's Nam (!" ------------------------------------------- -. ------------------.- Phone-------------------------------------- - ---------------•------------ - -- --------------------- - Address...-.i - -------- --------------------- Contractors Name S J ------- Phone------------•---------------------- ,Installation wiserve.,fR'esidence A artment House Commercial ❑ Trailer Court ❑ Motel El Other El Number of living units: _ ____ Number o ___ ❑ P ,r � f bedrooms __ ___ Number of baths_.�._. Lott size ._._-1._ -a------------------------------ - 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 El Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes E43,0' FHA/VA: Yes ❑ No ®— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is-available within 2004,feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--'±................Material________-_-__-.---._----._-_---_---__.___.__-_. ❑ No. of compartments---- -------------------Size._..-----------------f----------Liquid depth------------------ .-------Capacity------ ----•----------- Disposal Field: Distance from nearest well-----------------Distance from foundation------- Distance to nearest lot line--_____--_--_--- ❑ Number of lines-----------------------------------Length of each line_L _!_-----_-__1i-.__k__.Width of trench.__---__-._-,--------------------- Type of filter material--------------- ---_..Depth of filter material- '.-- _____Total- length------------------- ______________ Seepage Pit: Distance to nearest te.IL_/�--------------Distance from fo dation----/P_-------!-'.'Distance to nearest lot line.-�`- .-.__..- Number of pits_______ ____________Lining materiel______] . .._-_ ____Size: Diameter__ �__-.-.-__--.Depth_.....�,5--__---___-___- Cesspool: Distance from nearest well-_-----_I---_-.--Distance from foundation------------- ining—material----------------------__.____-_:-. Size: Diameter--------•-------------------1--- --_•De th--------------------- -- ---------------- -----Liquid Capacity gals. Privy: Distance from nearest well------ -----------------------------------------Distance from.nearest building------------------------------------------ ❑ Distance to nearest lot line----- --------=------------------------------------------------------- ------------- ----------------------------------------------- Remodeling and/or repairing (describe)=--------------f-------------,="-'-�l..--------• -----------------•-----•-- t •---------------------------•------------------------------------- ---------•------------------------------------------------•-------------------------------- ----'----------------------------------------------I-------- -------------- ----------------------------------------- 5 --------------•-------•---- ----------------------- - ---------------------------------------------------------------------- -- ---------- - I hereby certify that I have prepared this,application*and that the work will be doneI in accordance with San Joaquin County ordinances, State laws, and s d regu atians of the"San Joaquin Local Health District. l �` ------------- ------ Owner and/or Contractor (Signed) A I Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). f R D - ARTMENT 115E ONLY ., APPLICATION ACCEPTED BY--- -------------------- r f - •--- ---- - ---- ------------- ----=--------------DATE--- - -- - - --�--- - ---- -- REVIEWEDBY----------------------------------- ` ------------------------------------------------------------,DATE.--. =`� -------- ---------- BUILDING PERMIT ISSUED------------- - I DATES -- ---------------------------- --•-------- -- Alterations and/or recommendations:---------------I- J-`------------ ------------------------------------------------------- - ---------------------------------------------------- - -- - f '•-------- t r ---- - - --------------------- 1. ---14------ ' �� --------------------------------------------------------------- ------------------------------ -- z ----------------- _ /ftj/ - - --- p9. ---------- --------- Date-- FINAL INSPECTION BY:------/------- --- �� E C-0 SAN JOAQUIN LOCAL HEALTH'DISTRICT 130 South American Street 300 West Oak Streat 132 Sycamore Street. 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised V59 F.P.Co.