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APPLICATION FOR SANITATION PERMIT Permit No. --lo---7j-1.. (Complete in Duplicate) ` Date Issued .3��1-r7_ 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 LO ATIO -- - -- ---•-------------------------------------------------------------------•---------------------------- Owner's Name-----------•-- - - -•-------- - - --------------------•---- -------- - ------------------------------------------I Rhone------------------------------- Address. ------------------ Ai-�- --------------------------•--- ------------------------ ------------------ Contractor's'Name --- ------------------------------ --------------------------------------------- Phone----------------------------------- Installation will serve: Residence �partmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms --2 Number of baths __�___ Lot size _,__- -�_-1_�Q---------------------- Water Supply: Public system ❑ Community system ❑ Private Dspth to Wafer Table "W ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe "'P-ardpan ❑ Previous Application Made: Yes ❑ No 2 New Consfruction: Yes ❑ No [�HA/VA: Yes ❑ No RI— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) i Septic Ta k: Distance from nearest well__ --------Distance from foundation----lQ ___.__.Material----- e _ --- - - No. of compartments. _._,.---------------Size- _ --------Liquid depth_____ �y-.________Capacity---!1 -_____ Disposal eld: Distance from nearest well.- ---------Distance from foundatio _ ... to nearest lot line__ _______ __ Number of Tines-------- __. __Len--Length of each line.____A __.Width of trench__- ��____________/__ _jiffs___ ____ Type of filter erial_fDepth of filter material_____ ___________Total length_____ _.�_________________________ Seepage Pit: Distance to ne well. Distance om fgdndation_ ______.D' ±�,,e to nearest Ic line:__*p _ ________________Size: Diameter__.. pJI Number of its______ _____________ nin material ________De fh____ __-- ___________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_____--_____-_____________-_________- ❑ Size: Diameter---------------------------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------------------------__._____--- `Distance from nearest building___--__-_____________________-________- ❑ Distance to nearest lot line---------------------------------- Remodeling and/or repairing (describe)------------- 0F ---------------------------------------------------------------------- ---------------- ------------------------------------------------------------------------------_------.---------------------•-------------------------------------------------------•-----------------------_-------------------------------- -----------------------------------------------------------------------•------------------------------------------------------------ ----------------------------------------- ----------•----------------------------------- 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 rul s and reaulatio s of the San Joaquin Local Health District. (Signed)------------------ ----- ---- -- --- r �---={1H'�r'n+tsr'"eneE7cef- Contracto By:---------------------------------------------- -- ----------------------------------------(Title)----- �lr�, Ill-�------------------------- (Plot plan, showing size of lot, locat' P system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- ------------------------------------------- DATE---------------------------------------------- REVIEWED BY ---------- --- HATE ---- BUILPING PERMIT ISSUED----------------------------------- ---------------- ---------------------- DATE-------- ----------------- Itatio nd/or recommendations:--------------- -- ----------- -- - ---------------------------------------•--- ------------------- -----•-----------------•------------- �O ---- -- -------- - -- - - - - -------Q- ---_.!±""_""`_-'_ �4,v vQ-----i------------------------------ ------------------- ----•--- - ---------------------�-�--! i--- --- ------------------------------------- ------------------------------------------------------------- ----- ----------------------------------------------------------------------------•----- ------ -------------------------------------------------------- aAl�ll f INAL INSPECTIONY:----- -•-------------- --- ---- Date---4- - _,�.f t -------------------------------------- SAN JOAQUIN 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 . Revisea 1.57 F.P.CO. 3