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o=� APPLICATION FOR SANITATION PERMIT Permit No. [Complete in Duplicate] %, / Date Issued ____ _�5_/__) __ 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 Ordinances No. 549. JOB ADDRESS ANBD LLO�CAATIO�N_'1 ,�/ • Owner's Name------- J ------ ----- Phone------------------------------------ Address_.__.------—1-111100%.6 .....—------ -- -•----------------------- Address '------------------------- E, Contractor's Name---------------- ---• ---------------------------•- -- --------------------------------------------- Phone-----•------------•---••----------- i Installation will serve: Residence !Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --k—Number of bedrooms Number of baths __f___ Lot size _Z40__/;(.___ao!—________________________ Water Supply: Public system IT Community system ❑ Private ❑ Depth to Water Table ft. Characterof soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑f I No Pc ' New Construction: Yes ❑ No B-FHA/VA: Yes ❑ No A - TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) f Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material___________--__-__.-------_-______-____._ No. of compartments------------ -------Size------•-------------------- -•-Liquid depth-------------------------Capacity-------Dis osal ield: Distance from nearest weft_________________Distance from foundation----.---------------Distance to nearest lot line_______ r c Number of lines-----------------------------------Length of each line------- -----------------------Width of trench------------------------ _-`_:- Type of filter material________________________Depth of filter material-----------------------Total length___-_-----________-_-_____________________ be Seepage Pit: Distance to nearest well__1[<d!r&&_Distance from f ndation____ ......Distance to nearest lot 1ine__'±?e ------- i Number of pits--_-__l-------------Lining material___ _�__u___Size: Diameter_-„,?_r7------ Depth----- r __--_______________ Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material---------------.____________________- 1771 Size: Diameter-- I------------------•- ------------De th--------------------------------------- -----------Li uid Capacity als.\ n Privy: Distance from nearest well ____--------------------------------------------Distance from nearest building____________-__________________-_____-_. ❑ Distance to nearest lot line------ - •--------- -------------- --------------------------------- = --------------- Remodeling and repairing (describe)=---------------- •- ------------------------------------------------------------------- 1 Y -------------------------------------------------------------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 and regulations of the San Joaquin Local Health District. �Si ned g }--------------------- --`------6��'��- ----- ------------��-------------------------------------------------------------- ----- (�-�.Contractor) By--------------------------------------------- -- -- —�-----------------------------------------------(Title)--------- 7�1�2 --------------------- - (Plot plan, showing size of lot, Iota n of system in relation to wells, buildings, etc., can be placed on reverse side). - r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ------------- ------------ ------------------------- -------------- DATE------------------------------------ REVIEWEDBY ---- ----- ------- --- ---------------------------------------------- DATE--------- -------- BUILDING PERMIT ISSUED--------------`----- -- - ------ ------ - -- --------------------------------------------- DATE- - ----- Alterati nd/or recornmendatians---------•- ----- ---- ------------------------------------------------------------------- ---- !. � 1---------- ------------------------ ----F�----------------- r�-� - ---- ----------- --------- ----------- ------------ _---- ----- -------- ------------------- -- - FINAL INSPECTION BY:------- _ _-- _--_ f ✓-d ---- - ---------- Date---/-�-------------------•--------------------------- SAN ------- - - SAN /JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street i32 Sycamore Street:, 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revises 5.57 F.P.CO_